Methods and Compositions for Treating a Disease Condition in a Subject

ABSTRACT

Methods for treating a disease condition in a subject are provided. The subject methods are characterizing by enhancing at least one symptom of the disease condition in a manner effective to cause the subject to mount a compensatory response effective to treat the disease condition. Also provided are compositions, kits and systems for practicing the subject methods.

CROSS-REFERENCE TO RELATED APPLICATIONS

Pursuant to 35 U.S.C. § 119 (e), this application claims priority to thefiling date of: U.S. Provisional Patent Application Ser. No. 60/650,192filed on Feb. 3, 2005; U.S. Provisional Patent Application Ser. No.60/630,969 filed on Nov. 24, 2004; and U.S. Provisional PatentApplication Ser. No. 60/619,158 filed on Oct. 15, 2004; the disclosuresof which applications are herein incorporated by reference.

INTRODUCTION Background of the Invention

Reversing chronic conditions remains an elusive goal of medicine. Themodern medical paradigm based on blocking or promoting abnormal pathwaysoffers symptomatic benefit, but tolerance to therapy can develop andtreatment cessation can produce rebound symptoms and tachyphylaxis dueto compensatory mechanisms. Tolerance is defined as either a situationrequiring dose escalation to maintain the therapeutic effect or adecreasing response to the repeat similar dosing. A classic example isthe use of beta-blockers for hypertension, in which abnormally-highsympathovagal ratio represents one of the therapeutic targets. Withtime, chronic sympathetic blockade with beta-blockers may inducecompensatory elevation of sympathovagal ratio, thereby creating higherdosing requirements and the potential for rebound hypertension uponcessation.

SUMMARY OF THE INVENTION

Methods for treating a disease condition in a subject are provided. Thesubject methods include enhancing at least one symptom of the diseasecondition to be treated in a manner effective to cause the subject tomount a compensatory response effective to treat the disease condition.Also provided are compositions, kits and systems for practicing thesubject methods.

BRIEF DESCRIPTIONS OF THE DRAWINGS

FIG. 1 shows an exemplary embodiment of an electric energy applyingdevice operatively positioned in a subject's body in accordance withembodiments of the subject methods.

DESCRIPTION OF THE REPRESENTATIVE EMBODIMENTS

Methods for treating a disease condition in a subject are provided. Thesubject methods include enhancing at least one symptom of the diseasecondition in a manner effective to cause the subject to mount acompensatory response effective to treat the disease condition. Alsoprovided are compositions, kits and systems for practicing the subjectmethods.

Before the present invention is described in greater detail, it is to beunderstood that this invention is not limited to particular embodimentsdescribed, as such may, of course, vary. It is also to be understoodthat the terminology used herein is for the purpose of describingparticular embodiments only, and is not intended to be limiting, sincethe scope of the present invention will be limited only by the appendedclaims.

Where a range of values is provided, it is understood that eachintervening value, to the tenth of the unit of the lower limit unlessthe context clearly dictates otherwise, between the upper and lowerlimit of that range and any other stated or intervening value in thatstated range, is encompassed within the invention. The upper and lowerlimits of these smaller ranges may independently be included in thesmaller ranges and are also encompassed within the invention, subject toany specifically excluded limit in the stated range. Where the statedrange includes one or both of the limits, ranges excluding either orboth of those included limits are also included in the invention.

Unless defined otherwise, all technical and scientific terms used hereinhave the same meaning as commonly understood by one of ordinary skill inthe art to which this invention belongs. Although any methods andmaterials similar or equivalent to those described herein can also beused in the practice or testing of the present invention, representativeillustrative methods and materials are now described.

All publications and patents cited in this specification are hereinincorporated by reference as if each individual publication or patentwere specifically and individually indicated to be incorporated byreference and are incorporated herein by reference to disclose anddescribe the methods and/or materials in connection with which thepublications are cited. The citation of any publication is for itsdisclosure prior to the filing date and should not be construed as anadmission that the present invention is not entitled to antedate suchpublication by virtue of prior invention. Further, the dates ofpublication provided may be different from the actual publication dateswhich may need to be independently confirmed.

It is noted that, as used herein and in the appended claims, thesingular forms “a”, “an”, and “the” include plural referents unless thecontext clearly dictates otherwise. It is further noted that the claimsmay be drafted to exclude any optional element. As such, this statementis intended to serve as antecedent basis for use of such exclusiveterminology as “solely,” “only” and the like in connection with therecitation of claim elements, or use of a “negative” limitation.

As will be apparent to those of skill in the art upon reading thisdisclosure, each of the individual embodiments described and illustratedherein has discrete components and features which may be readilyseparated from or combined with the features of any of the other severalembodiments without departing from the scope or spirit of the presentinvention. Any recited method can be carried out in the order of eventsrecited or in any other order which is logically possible.

Overview

Aspects of the invention include methods of treating a subject for adisease condition. In the subject methods, at least one symptom of thedisease condition is enhanced in a manner effective to cause the subjectto mount a compensatory response effective to treat the diseasecondition. By “enhanced” is meant that the magnitude of the symptom isincreased. In other words, the target symptom or symptoms isexacerbated. In certain embodiments, the magnitude of enhancement is atleast about two-fold, e.g., at least about 5-fold, or more. The term“symptom” is used broadly to refer to any characteristic or sign of thedisease condition, i.e., parameter, where symptoms may be any of anumber of different types of parameters, including, but not limited to:sympathovagal ratio, high blood pressure, shortness of breath,variations from normal of one or more blood analytes, depression,sleeplessness, and the like. Representative parameters of interest andranges that can be employed as reference values are provided in Table 1,below:

TABLE 1 Normal Range Range of Parameter Test of Values Interestpulmonary gas Alveolar oxygen 650-713 mmHg 600-713 mmHg serum blood gaspH 7.35-7.45 7.1 to 7.7  arterial pO2 80-100 mmHg 50-110 arterial pcO235-45 mmHg 10 to 80  arterial bicarb 25-35 meq/L 10 to 40 alveolar/oxygen ratio    0.8  1 to 0.6 aa gradient 10-15 mmHg  5 to 120venous oxygen sat  60%  30-80% cardoipulmonary cardiac output 3.5 to 5.5L/min 1 to 6  cardiac index 2.8-3.2 L/min/m2 0.5 to 6   right atrialpressure 1-7 mmHg 1 to 30 right ventricular 15-25 mmHg 5 to 50 systolicpressure right ventricular 0-8 mm Hg 1 to 50 diastolic pressurepulmonary arterial 15-25 mmHg 5 to 50 systolic pressure pulmonaryarterial 8-15 mmHg 1 to 30 diastolic pressure mean pulmonary 10-20 mmHg5 to 50 arterial pressure pulmonary capillary 6-12 mmHg 1 to 20 wedgepressure pulmonary tidal volume 8-15 ml/Kg 2-20 or 20-80% function testtotal lung capacity 5-7 liters 3 to 10 or 20-120% residual volume 1.5 to2.5 liters 0.5 5 or 20-120% forced expiratory 3.5-4 liters 0.5 to 6 or20-120% volume in 1 second functional vital 4-6 liters 0.5 to 6 or20-120% capacity FEV1/FVC ratio >75%   20-120% forced expiratory  75-125%   50 to 150% flow peak expiratory flow   80-100%   60-120%rate forced expiratory <5 seconds 0-20 seconds time corrected diffusion  75-80%   60-140% capacity corrected QT interval <440  <600 sleep studysleep latency >10 min 0-1 hour total sleep time >5.5 hours 0-12 hourspercent rem >15% of TST 0-40% total sleep time percent stage 3-4 >25% ofTST 0-50% total sleep non rem time respiratory arousal <5/hour total0-40/hour total index sleep time sleep time periodic leg <1/hour total0-40/hour total movements sleep time sleep time apnea index <1/hourtotal 0-20/hour total sleep time sleep time hypopnea index <3/hour total0-40/hour total sleep time sleep time nadir oxygen >92%   40-100%saturatin mean oxygen >95%   40-100% saturation desaturation index <5defined 0-40 defined as >4% for 5 as >4% for 5 seconds/hour ofseconds/hour of total sleep time total sleep time highest carbon 52 mmHg 10-80 mmHg dioxide carbon dioxide >45 <20% of total 0-60% of totalmmHg sleep time sleep time Serum Markers Catecholamine levelsAcetycholine levels 650-1500 IU/L 300-2000 IU/L Aldosterone levels 17-70nmol/day 5-150 nmol/L/day Renin levels 7-76 uU/mL 3-200 uU/mlVasopressin levels 2-8 pg/mL 1-20 pg/ml angiotensin 25-100 IU/L 5-200U/L converting enzyme levels interleukin 1-3 and modulate 5-13 and 18Interleukin 4 decrease interferon alpha and modulate beta interferongamma increase tumor necrosis factor modulate alpha transforming growthmodulate factor hemoglobin A1C   4-8%   2-12% Fasting glucose 3.5-6.0mmol/L 1-10 mmol/L high density 45-60 10 to 90  lipoprotein low density 95-130 60-200 lipoprotein triglyceride <2 mmol/L 4 to 4 mmol/L betanatriuretic 20-40 pg/mL 0-100 pg/mL peptide alpha natriuretic 20-40pg/mL 0-50 pg/mL peptide erythrocyte 0-35 mm/Hour 1-200 mm/Hoursedimentation rate c reactive peptide <10 mg/L 1-80 mg/L transferrin1.75 to 3.13 g/L 0.5 to 6 g/L Hemloglobin 135-160 gm/L 25 to 300 gm/Lhematocrit   37-54%  25-60% ferritin 20-240 ug/L 5 to 600 ug/L iron10-40 umol/L 5 to 100 umol/L cholinesterase 650-1500 IU/L 200-2500 IU/LUrine adrenaline 0-80 nmol/day 0-200 nmol/day Urine noradrenaline 0-780nmol/day 0-1600 nmol/day Urine dopamine 0-3500 nmol/day 0-7000 nmol/dayadrenocorticotrophic <19 pmol/L 0 to 40 pmol/L hormone antidiuretichormone 2-8 pg/mL 1-20 pg/mL thrombin clotting 10-20 secs 5-30 secs timetotal serum 110-120 100-300  cholesterole Additional body mass index20-30  <40 systolic blood <125  90-180 pressure diastolic blood <7530-100 pressure pulse pressure <20 20-40  heart rate  60-100 30-200heart rate variability increase respiratory sinus increase arrhythmia

In practicing the subject methods, the target symptom(s) is enhanced byapplying an appropriate stimulus to the subject, where the stimulus isof a nature and magnitude sufficient to achieve the desired enhancement.In certain embodiments, the applied stimulus is one of short duration,where by short duration is meant that the applied stimulus lasts forless than about 1 week, e.g., less than about 3 days, e.g., less thanabout 1 day, e.g., less than about 12 hours, where the duration of theapplied stimulus may be even shorter. Where the stimulus is apharmacological stimulus, the duration refers to the period in which thepharmacological agent from an administered dosage is active. Where thestimulus is an electrical stimulus, the duration refers to the total ofelectrical applications received by a subject over a given period,analogous to a dose of a pharmacological agent.

Following symptom enhancement via an applied stimulus, as describedabove, the stimulus is removed, e.g., by metabolization of thepharmacological agent or cessation of application of electrical energy,and the subject is permitted to mount a compensatory response. In thisfollowing period, no additional stimulus is administered to the subject.The duration of this period between stimulus application, which may bereferred to as a “holiday” period, may vary, but in representativeembodiments is at least about 1 day, such as at least about 2 days,including at least about 5 days, at least about 10 days, at least about15 days, or longer. As such, embodiments of the methods includenon-chronic (i.e., non-continuous) application of the stimulus, e.g.,non-chronic administration of a pharmacologic agent.

In certain embodiments, the methods include close monitoring orsupervision of the subject during and/or after application of thestimulus. This monitoring may be completely automated, or at least inpart performed manually, e.g., by a health care professional. Forexample, a health care professional can closely watch the subjectfollowing application of the stimulus as well as during the holidayperiod following stimulus application, and based on this monitoringdetermine when a next stimulus should be applied. Monitoring alsoassures that the symptom enhancement is not so severe as to beultimately damaging to the subject at an unacceptable level. Certainaspects of the monitoring may be automated. For example, followingadministration, the subject may enter one or more physiologicalparameters into an automated system, which uses the input parameters toautomatically determine whether the subject is staying within apredetermined set of physiological parameters, or whether interventionis necessary. In certain embodiments, the automated monitoring systemmay also be integrated with a stimulus application device, such that thesystem, based on monitored parameters, determines when next toadminister a stimulus, the duration of the next stimulus, etc. As such,the method may be characterized as applying a first stimulus to thesubject and monitoring the subject for a response thereto. Followingthis first step, the method further includes applying at least a secondstimulus to the subject, wherein the second stimulus is determined basedon the monitored response to the first stimulus.

In certain embodiments, stimulus to the subject is done in an“irregularly irregular” manner. As such, duration of the stimulusapplication events, as well as duration of holiday periods between suchevents, varies randomly over the entire course of a treatment, or atleast a portion thereof. In addition, the variation does not follow anypattern, but instead is random.

In practicing the subject methods, the applied stimulus may vary, wherein representative embodiments the stimulus may be a pharmacologicalstimulus and/or an electrical stimulus. As such, in certain embodiments,the stimulus is a pharmacological stimulus. In other representativeembodiments, the stimulus is an electrical stimulus. In yet otherembodiments, the stimulus is a combination of pharmacological andelectrical stimuli. Accordingly, in certain embodiments, the enhancingis by administering a pharmacological agent to the subject. In yet otherembodiments, the enhancing is by electrical stimulation, e.g., byemploying an implanted electrical energy application device.

A variety of different disease conditions are treatable by the subjectmethods. In certain embodiments, the disease condition is one in whichthe body mounts a compensatory response to a stimulus administered tosuppress or decrease one or more symptoms of the disease. In otherwords, the disease condition is one that is characterized by thepresence of a compensatory response to a stimulus that reduces themagnitude of one or more symptoms of the disease. In certainembodiments, the disease condition is a condition that is characterizedby the presence of a compensatory mechanism to a directly actingtherapeutic approach.

In certain embodiments, the disease condition is a manifestation of anirregularity in a homeostatic pathway. In certain embodiments, thedisease condition is manifested by chronic sympathetic bias. In certainembodiments, the pharmacological agent is adrenergic agonist, where theagent enhances the sympathetic bias in the short term, thereby causingthe body to mount a compensatory mechanism. In certain embodiments, thestimulus is application of electrical energy that stimulates asympathetic nerve(s) in a manner that enhances the sympathetic bias inthe short term, thereby causing the body to mount a compensatorymechanism.

In certain embodiments, the disease condition is a cardiovasculardisease. For example, short-term administration of adrenergic agonistsmay be employed in the treatment of hypertension, e.g., to achieve thedesired short term increase or enhancement of sympathetic bias andconcomitant long term decrease in sympathetic bias. In certainembodiments, the disease condition is a neurological condition. Forexample, short-term administration of a serotonin antagonist may beemployed to treat depression, by causing a long-term compensatoryresponse in the body in the form of increased serotonin receptorsensitivity. In certain embodiments, the disease condition is an immunecondition. For example, a proinflammatory agent may be administered inshort duration to treat asthma, where the short duration ofproinflammatory agent cause the body to mount a compensatory responsethat results in decreased inflammation. In certain embodiments, thedisease condition is an endocrine system condition. For example, in thetreatment of diabetes, an insulin blocker may be administered on a shortterm basis, causing the body to mount a compensatory response, e.g., inthe form of increased insulin receptor sensitivity. See the experimentalsection below for further discussion of these representativeembodiments. In certain embodiments, the disease is not a pulmonaryairway disease, e.g., asthma, emphysema or chronic obstructive pulmonarydisease.

If a pharmacological approach is employed in the treatment of a givendisease, the specific nature and dosing schedule of the agent will varydepending on the particular nature of the disease to be treated.Representative pharmacological agents that may find use in certainembodiments of the subject invention include both pro parasympatheticand pro sympathetic agents.

Pro parasympathetic agents of interest include, but are not limited to:Beta Blockers, e.g., atenolol (Tenormin R), betaxolol (Kerone R),bisoprolol (Zebeta R), carvedilol (Coreg R), esmolol (Brevibloc R),labetalol (Normodyne R), metoprolol (Lopressor R), nadolol (Corgard R),pindolol (Visken R), propranolol (Inderal R), sotalol (Betapace R),timolol (Blocadren R); Aldosterone Antagonists, e.g., Spironolactone,eplerenone, Angiotensin II Receptor Blockade, candesartan (Atacand R),irbesartan (Avapro R), losartan (Cozaar R), telmisartin (Micardis R)valsartan (Diovan R), eprosartan mesylate (Teveten); ACE inhibitors,e.g., Benazepril (Lotensin R), Captopril (Capoten R), Enalapril (VasotecR), Fosinopril (Monopril R), Lisinopril (Prinivil R), Moexipril (UnivascR), Quinapril (Accupril R), Ramipril (Altace R), Trandolapril (Mavik R);Statins, e.g., atorvastatin (Lipitor R), cerivastatin (Baycol R),fluvastatin (Lescol R), lovastatin (Mevacor R), pravastatin (PravacholR), mvastatin (Zocor R); Triglyceride Lowering Agents, e.g., fenofibrate(Tricor R), gemfibrozil (Lopid R), Niacin; Diabetes Agents, e.g.,acarbose (Precose R), glimepiride (Amaryl R), glyburide (Micronase R,Diabeta R), metformin (Glucophage R), Miglitol (Glycet R), pioglitazone(Actos R), repaglinide (Prandin R), rosiglitazone (Avandia R);Immunomodulators, e.g., Interferon Alfa-2A (Roferon-A), InterferonAlfa-2b (Intron-A), Interferon Alfa-2b and Ribavirin combo Pack(Rebetron), Interferon Alfa-N3 (Alferon N), Interferon Beta-1A (Avonex),Interferon Beta-1B (Betaseron), Interferon Gamma; agentsthatbinds/reacts to CD4, gp39, B7, CD19, CD20, CD22, CD401, CD40, CD40Land CD23 antigens, rituximab, Nicotine; Sympathomimetics, e.g.,trimethaphan, Clonidine, Reserpine, Guanethidine; Antihistamines, e.g.,Benadryl, Diphenhydramine, Actifed (Triprolidine), PBZ (Tripelenamine),Allegra (Fexofenadine), Periactin (Cyproheptadine), Antivert or Bonine(Meclizine), Phenergan (Promethazine), Astelin (dispensed as a NoseSpray), Polyhistine (Phenyltoloxamine), Atarax (Hydroxyzine), Seldane(Terfenadine), Benadryl (Diphenhydramine), Semprex (Acrivastine),Bromfed (Brompheneramine), Tavist (Clemastine), Chlortrimeton(Chlorpheniramine), unisom (Doxylamine), Claritin (Loratidine), Zyrtec(Cetirizine), Dramamine (Dimenhydrinate); Cholinergics, e.g.,Bethanechol, Oxotremorine, Methacholine, Cevimeline, Carbachol,Galantamine, Arecoline, Levaminsole; Acetylcholinesteriase Inhibitors,e.g., Edrophonium, Neostigmine, Donepezil, Tacrine, Echothiophate,Diisopropylfluorophosphate, Demecarium, Pralidoxime, Galanthamine,Tetraethyl pyrophosphate, Parathoin, Malathion, Isoflurophate,Metrifonate, Physostigmine, Rivastigmine, Abenonium, acetylchol,Carbaryl acetylchol, Propoxur acetylchol, Aldicarb acetylchol,Muscarinics, Muscarine, Pilocarpine, Magnesium; Calcium channelblockers, e.g., amlodipine besylate, Norvasc, diltiazem hydrochlorideCardizem CD, Cardizem SR, Dilacor XR, Tiazac, felodipine Plendil,isradipine DynaCirc, DynaCirc CR, nicardipine Cardene SR, nifedipineAdalat CC, Procardia XL, nisoldipine Sular, verapamil hydrochlorideCalan SR, Covera HS, Isoptin SR, Verelan; Sodium channel blockers, e.g.,moricizine, propafenone, encainide, flecainide, Tocainide, mexiletine,Phenytoin, Lidocaine, Disopyramide, Quinidine, Procainamide;Glucocorticoid receptor blocker, e.g., (Mifepristone); Peripheraladrenergic inhibitors, e.g., guanadrel Hylorel, guanethidine,monosulfate Ismelin, reserpine Serpasil, Mecamylamine, Hexemethonium;Blood vessel dilators, e.g., hydralazine hydrocholoride Apresoline,minoxidil Loniten; Central agonists, e.g., alpha methyldopa Aldomet,clonidine hydrochloride Catapres, guanabenz, acetate Wytensin,guanfacine hydrochloride Tenex; Combined alpha and beta blockers, e.g.,labetolol hydrochloride, Normodyne, Trandate, carvedilol Coreg; Alphablockers, e.g., doxazosin mesylate Cardura, prazosin hydrochlorideMinipress, terazosin, hydrochloride Hytrin; Combination diuretics, e.g.,amiloride hydrochloride+hydrochlorothiazide Moduretic,spironolactone+hydrochlorothiazide Aldactazide,triamterene+hydrochlorothiazide Dyazide, Maxzide; Potassium-sparingdiuretics, e.g., amiloride hydrochloride Midamar, spironolactoneAldactone, triamterene Dyrenium; Nitrate pathway modulators, e.g.,L-arginine, Nitroglycerin Deponit, Minitran, Nitropar, Nitrocine, NitroDisc, Nitro-Dur, Nitrogard, Nitroglycerin, Nitroglycerin T/R,Nitro-Time, Nitrol ointment, Nitrolingual Spray, Nitrong, Nitro-Bid,Nitropress, Nitroprex, Nitro S.A., Nitrospan, Nitrostat, Nitro-TransSystem, Nitro-Transdermal, Nitro-Time, Transderm-Nitro, Tridil.Pentaerythrito, I Tetranitrate, Peritrate, Peritrate S.A, Erythrityl,Tetranitrate, Cardilate, Isosorbide Dinitrate/Phenobarbital Isordil w/PBIsosorbide, Mononitrate, Imdur, ISMO, Isosorbide, Mononitrate, Monoket,Isosorbide, Nitrate; Cyclic nucleotide monophosphodiesterase (PDE)inhibitors; e.g., Levitra (vardenafil), Cialis (tadalafil), Viagra(sildenafil); Vasopressin inhibitors, e.g., atosiban, Alcohol, Relaxin;Renin inhibitors; e.g., Aliskiren; Estrogen and estrogen analogues andestrogen metabolites; Vesicular monoamine transport (VMAT) inhibitors;e.g., reserpine, tetrabenazine, Melatonin, Melatonin Analogues,6-chloromelatonin, 2,3, dihydromelatonin, 6-chloro-2,3-dihydromelatonin,N-acetyl-N2-formyl-5-methoxy, kynurenamine, N-acetyl-5-methoxykynurenamine; Progestrone inhibitors, e.g, ru486; Testosteroneinhibitors, e.g., Spironolactone, cyproterone acetate;Gonadotropin-releasing hormone inhibitors, e.g., Leuprolide Acetate;Oxytocin inhibitors, e.g., Terbutaline Ritodrine, Glucagon Like Peptide1; Dipeptidyl Peptidase IV inhibitors, e.g., LAF237 (novartis), P93/01and P32/98 (Probiodrug AB), valine pyrrolidide (Novo Nordisk), dhea,adiponectin, phenserine, phosphodiesterase 4 inhibitor, valproate;Anticoagulants, e.g., Exanta (ximelagatran)-, Bilivarudin (hirulog),abciximab (Reopro @), Aggrenox® (dipridamole/ASA), anagrelide (Agrylin@), clopidogrel (Plavix), dipyridamole (Persantine @), tifabatide(Integrelin), ticlopidine (Ticlid 0), tirofiban (aggrastat), ardeparin(Normiflo), Dalteparin (Fragmin), Danaparoid (Orgaran), Enoxaparin(lovenox), lepirudin (Refludan), Heparin, Warfarin; Thrombolytics, e.g.,alteplase (Activase®, t-PA), reteplase (Retevase), Streptokinase,Urokinase; Other anticoagulants, e.g., aminocaproic acid (Amicar 0),cilostazol (Pletal), erythropoietin (Epogen), filgrastim (G-CSF,Neupogen 0), oprelvekin (Neumega), pentoxifylline (Trental); hmglantagonist; botox; and the like.

Pro sympathetic agents of interest include, but are not limited to:Beta-agonists, e.g., dobutamine, terbutaline, ritodrine, albuterol,metaproterenol; Alpha-1 agonists, e.g., phenylephrine, metaraminol,methoxamine; Prednisone & steroids; Indirect agents that include, butare not limited to, NE, ephedrine, phenylpropanolamine, cyclopentamine,tuaminoheptane, naphazoline, ampthetamine, tetrahydrozoline;Epinephrine/norepinephrine, Acetylcholine, Sodium, Calcium, ACE,Angiotensin, Aldosterone, Aldosterone Analogues, Fludrocortisone,18-oxocortisol, deoxycorticosterone pivalate (DOCP) (ciba-geigy animalhealth); Potassium or magnesium channel blockers, e.g., valproatelithium, Cocaine; Amphetamines, e.g., Ephedrine, Terbutaline, Dopamine,Bromocriptine (Parlodel), Levodopa/Carbidopa, Dobutamine; Acupunture;Adh vasopressin; Oxytocin pitocin; THC cannabinoids; Progesterone;Leptin; Galanin like peptide

In certain embodiments, the pharmacologic agent that is administered isnot an inverse agonist as defined in publication nos. WO 2005/034871 andWO 2005/035731, such that it is not a substance that has an affinity forthe inactive state of a receptor and thereby stabilizes the inactivestate of the receptor, or a substance, including, but not limited to,drugs, hormones, or neurotransmitters, that produces inactivation ofreceptors and/or prevents or hinders activation by agonists, therebyreducing signaling from those receptors. In certain embodiments, theagent is not nadolol, bupranolol, butoxamine, carazolol, carvedilol,ICI-118, 551, levobunolol, metoprolol, propranolol, sotalol, andtimolol, and the salts, solvates, analogues, congeners, bioisosteres,hydrolysis products, metabolites, precursors, and prodrugs thereof. Incertain embodiments, the agent is not a “pressor” agent, such that itdoes not increase blood pressure.

Administering a Pharmacological Agent

In certain embodiments, the subject invention includes administering aneffective amount of a pharmacological agent to a subject. Any suitablepharmacological agents may be administered. That is, embodiments of thesubject methods include administering an effective amount, i.e., atherapeutically effective amount, of one or more pharmacological agentsto a subject. By “effective amount” is meant a dosage sufficient tocause the subject to mount a compensatory response effective to treatthe subject, as desired. The effective amount will vary with the age andphysical condition of the subject, severity of the condition beingtreated, the duration of the treatment, the nature of any concurrenttreatment, the pharmaceutically acceptable carrier used if any, andanalogous factors within the knowledge and expertise of those skilled inthe art.

In certain embodiments, more than one type of agent may be administeredat the same or different times to treat the same or different condition.The effective amount of a given agent may vary somewhat from subject tosubject, and may depend upon factors such as, but not limited to, theage and condition of the subject, the form of the agent, the route andmethod of delivery, etc., as noted above. Dosages may be determined inaccordance with routine pharmacological procedures known to thoseskilled in the art.

Depending on the particular agent(s) administered to a subject, theagent(s) may be administered to a subject using any convenient means.Thus, a pharmacological agent may be incorporated into a variety offormulations for administration to a subject. A pharmacological agentmay be formulated into pharmaceutical compositions by combination withappropriate, pharmaceutically acceptable carriers. By “pharmaceuticallyacceptable carrier” is meant a component such as a carrier, diluent,excipient, and the like of a composition that is compatible with the oneor more pharmacological agents and other optional ingredients of thesubject pharmacological agent compositions in that a pharmaceuticallyacceptable carrier may be combined with the pharmacological agent(s)without eliminating the biological or therapeutically effective activityof the one or more pharmacological agents, and is suitable for use insubjects as provided herein without undue adverse side effects (such astoxicity, irritation, allergic response, and death). Side effects are“undue” when their risk outweighs the benefit provided by thepharmaceutical agent. Non-limiting examples of pharmaceuticallyacceptable components include, but are not limited to, any of thestandard pharmaceutical carriers such as phosphate buffered salinesolutions, water, emulsions such as oil/water emulsions or water/oilemulsions, microemulsions, and various types of wetting agents.Accordingly, the pharmacological agents employed in the subject methodsmay be formulated into preparations in solid, semi-solid (e.g., gel),liquid or gaseous forms, such as tablets, capsules, powders, granules,ointments, solutions, suppositories, injections, inhalants and aerosols.As such, administration of a pharmacological agent may be achieved invarious ways, including, but not limited to, oral, buccal (e.g.sub-lingual), rectal, topical (including both skin and mucosal surfaces,including airway surfaces), parenteral (e.g., subcutaneous,intramuscular, intradermal, intravenous and intrathecal),intraperitoneal, transdermal, intracheal, intravaginal, endocervical,intrathecal, intranasal, intravesicular, in or on the eye, in the earcanal, etc., administration. In certain embodiments, one or morepharmacological agents may be administered via a transdermal patch orfilm system such as or analogous to that described, e.g., in U.S. Pat.Nos. 6,503,532; 5,302,395; 5,262,165; 5,248,501; 5,232,702; 5,230,896;5,227,169; 5,212,199; 5,202,125; 5,173,302; 5,154,922; 5,139,786;5,122,383; 5,023,252; 4,978,532; 5,324,521; 5,306,503; 5,302,395;5,296,230; 5,286,491; 5,252,334; 5,248,501; 5,230,896; 5,227,169;5,212,199; 5,202,125; 5,173,302; 5,171,576; 5,139,786; 5,133,972;5,122,383; 5,120,546; 5,118,509; 5,077,054; 5,066,494; 5,049,387;5,028,435; 5,023,252; 5,000,956; 4,911,916; 4,898,734; 4,883,669;4,882,377; 4,840,796; 4,818,540; 4,814,173; 4,806,341; 4,789,547;4,786,277; 4,702,732; 4,690,683; 4,627,429; and 4,585,452, thedisclosures of which are herein incorporated by reference.

Embodiments may include pharmacological agent formulations for oraladministration that may be formulated using pharmaceutically acceptablecarriers well known in the art in dosages suitable for oraladministration. Such carriers enable the pharmaceutical formulations tobe formulated in unit dosage forms as tablets, pills, powder, dragees,capsules, liquids, lozenges, gels, syrups, slurries, suspensions, etc.,suitable for ingestion by the patient. Pharmaceutical preparations fororal use may be obtained through combination of at least onepharmacological agent with a solid excipient, optionally grinding aresulting mixture, and processing the mixture of granules, after addingsuitable additional compounds, if desired, to obtain tablets or drageecores. Suitable solid excipients include, but are not limited to,carbohydrate or protein fillers and include, but are not limited tosugars, including lactose, sucrose, mannitol, or sorbitol; starch fromcorn, wheat, rice, potato, or other plants; cellulose such as methylcellulose, hydroxypropylmethyl-cellulose or sodiumcarboxymethylcellulose; and gums including arabic and tragacanth; aswell as proteins such as gelatin and collagen. If desired,disintegrating or solubilizing agents may be added, such as thecross-linked polyvinyl pyrrolidone, agar, alginic acid, or a saltthereof, such as sodium alginate; with optional lubricants, such as talcor magnesium stearate; and if desired, with diluents, buffering agents,moistening agents, preservatives and flavoring agents.

Accordingly, pharmacological agent formulations suitable for oraladministration in accordance with the subject invention may be presentin discrete units, such as capsules, cachets, lozenges, tablets, and thelike, each containing a predetermined amount of the activepharmacological agent; as a powder or granules; as a solution or asuspension in an aqueous or non-aqueous liquid; or as an oil-in-water orwater-in-oil emulsion. Such pharmacological agent formulations may beprepared by any suitable method of pharmacy which includes, but is notlimited to, bringing into association the active pharmacological agentand a suitable carrier (which may contain one or more optionalingredients as noted above). For example, pharmacological agentformulations for use with the subject invention may be prepared byuniformly and intimately admixing the active pharmacological agent(s)with a liquid or finely divided solid carrier, or both, and then, ifnecessary, shaping the resulting mixture. For example, a tablet may beprepared by compressing or molding a powder or granules containing theactive pharmacological agent, optionally with one or more accessoryingredients. Compressed tablets may be prepared by compressing, in asuitable machine, the pharmacological agent in a free-flowing form, suchas a powder or granules optionally mixed with a binder, lubricant, inertdiluent, and/or surface active/dispersing agent(s). Molded tablets maybe made by molding, in a suitable machine, the powdered pharmacologicalagent moistened with an inert liquid binder.

Pharmacological agents may also be administered in the form ofsuppositories for rectal administration of the drug. These formulationsmay be prepared by mixing a pharmacological agent with a suitablenon-irritating vehicle or excipient which is solid at ordinarytemperatures but liquid at the rectal temperatures and will thereforemelt in the rectum to release the drug. Such materials include, but arenot limited to, cocoa butter, carbowaxes and polyethylene glycols.Embodiments include one or more pharmacological agent(s) made intosuppositories by mixing with a variety of bases such as emulsifyingbases or water-soluble bases.

Pharmacological agents may also be administered by intranasal,intraocular, intravaginal, and intrarectal routes includingsuppositories, insufflation, powders and aerosol formulations (forexamples of steroid inhalants, see Rohatagi, J. Clin. Pharmacol.35:1187-1193, 1995; Tjwa, Ann. Allergy Asthma Immunol. 75:107-111,1995).

For example, embodiments may also include at least one pharmacologicalagent in an aerosolized, atomized or nebulized vapor form, e.g.,administrable via a metered dose device or nebulizer, and the like suchthat embodiments also include aerosolizing, vaporing or nebulizing oneor more pharmacological agents for administration to a subject.Accordingly, the one or more pharmacological agent agents may beutilized in aerosol formulation or an analogous formulation to beadministered via inhalation or analogous means. The one or morepharmacological agents employed in the practice of the present inventionmay be formulated into pressurized acceptable propellants such asdichlorodifluoromethane, propane, nitrogen and the like.

Pharmacological agents may be delivered transdermally, by a topicalroute, formulated as applicator sticks, solutions, suspensions,emulsions, gels, creams, ointments, pastes, jellies, paints, powders,and aerosols. For example, embodiments may include a pharmacologicalagent formulation in the form of a discrete patch or film or plaster orthe like adapted to remain in intimate contact with the epidermis of therecipient for a period of time. For example, such transdermal patchesmay include a base or matrix layer, e.g., polymeric layer, in which oneor more pharmacological agent(s) are retained. The base or matrix layermay be operatively associated with a support or backing. Pharmacologicalagent formulations suitable for transdermal administration may also bedelivered by iontophoresis and may take the form of an optionallybuffered aqueous solution of the pharmacological agent compound.Suitable formulations may include citrate or bis/tris buffer (pH 6) orethanol/water and contain a suitable amount of active ingredient.

Pharmacological agents may be provided as a salt and may be formed withone or more acids, including but not limited to hydrochloric, sulfuric,acetic, lactic, tartaric, malic, succinic, etc. Salts tend to be moresoluble in aqueous or other protonic solvents that are the correspondingfree base forms. In other cases, a preparation may be a lyophilizedpowder that is combined with buffer prior to use.

Pharmacological agents may administered parenterally, such asintravenous (IV) administration, and may include a solution of thepharmacological agent dissolved in a pharmaceutically acceptablecarrier. Among the acceptable vehicles and solvents that may beemployed, include, but are not limited to, water and Ringer's solution,an isotonic sodium chloride, etc. In addition, sterile fixed oils mayconventionally be employed as a solvent or suspending medium. For thispurpose any bland fixed oil may be employed including synthetic mono- ordiglycerides. In addition, fatty acids such as oleic acid can likewisebe used in the preparation of injectables. Accordingly, apharmacological agent may be formulated into preparations for injectionby dissolving, suspending or emulsifying them in an aqueous ornonaqueous solvent, such as vegetable or other similar oils, syntheticaliphatic acid glycerides, esters of higher aliphatic acids or propyleneglycol; and if desired, with conventional additives such assolubilizers, isotonic agents, suspending agents, emulsifying agents,stabilizers and preservatives. These solutions are sterile and generallyfree of undesirable matter. These formulations may be sterilized byconventional, well known sterilization techniques. The formulations maycontain pharmaceutically acceptable auxiliary substances as required toapproximate physiological conditions such as pH adjusting and bufferingagents, toxicity adjusting agents, e.g., sodium acetate, sodiumchloride, potassium chloride, calcium chloride, sodium lactate and thelike. The concentration of pharmacological agent in these formulationsmay vary widely, and will be selected based on fluid volumes,viscosities, body weight, and the like, in accordance with theparticular mode of administration selected and the patient's needs. ForIV administration, the formulation may be a sterile injectablepreparation, such as a sterile injectable aqueous or oleaginoussuspension. This suspension may be formulated according to the known artusing those suitable dispersing or wetting agents and suspending agents.The sterile injectable preparation may also be a sterile injectablesolution or suspension in a nontoxic parenterally-acceptable diluent orsolvent, such as a solution of 1,3-butanediol, and the like.Accordingly, pharmacological agent formulations suitable for parenteraladministration may include sterile aqueous and non-aqueous injectionsolutions of one or more active pharmacological agents, whichpreparations may be isotonic with the blood of the intended recipient.These preparations may contain, buffers and solutes which render theformulation isotonic with the blood of the intended recipient. Aqueousand non-aqueous sterile suspensions may include suspending agents andthickening agents. The formulations may be presented in single- ormulti-dose containers, for example sealed ampoules and vials, and may bestored in a freeze-dried (lyophilized) condition requiring only theaddition of the sterile liquid carrier, for example, saline orwater-for-injection immediately prior to use. Extemporaneous injectionsolutions and suspensions may be prepared from sterile powders, granulesand tablets of the kind described above.

Pharmacological agents may be delivered by the use of liposomes whichfuse with the cellular membrane or are endocytosed, i.e., by employingligands attached to the liposome, or attached directly to theoligonucleotide, that bind to surface membrane protein receptors of thecell resulting in endocytosis. By using liposomes, particularly wherethe liposome surface carries ligands specific for target cells, or areotherwise preferentially directed to a specific organ, one can focus thedelivery of the pharmacological agent into the target cells in vivo.(See, e.g., AI-Muhammed, J. Microencapsul. 13:293-306, 1996; Chonn,Curr. Opin. Biotechnol. 6:698-708, 1995; Ostro, Am. J. Hosp. Pharm.46:1576-1587, 1989). Accordingly, embodiments may include one or morepharmacological agents administered as liposomal formulations of thepharmacological agents. Methods for preparing liposomal suspensions areknown in the art and thus will not be described herein in great detail.Briefly, in those embodiments where the pharmacological agent is anaqueous-soluble pharmacological agent, the pharmacological agent may beincorporated into lipid vesicles using conventional liposome technology.In such instances, due to the water solubility of the pharmacologicalagent, the pharmacological agent may be substantially entrained withinthe hydrophilic center or core of the liposomes. The lipid layeremployed may be of any conventional composition and may either containcholesterol or may be cholesterol-free. When the pharmacological agentof interest is water-insoluble, the pharmacological agent may besubstantially entrained within the hydrophobic lipid bilayer which formsthe structure of the liposome employing conventional liposome formationtechnology. In either instance, the liposomes which may be produced maybe reduced in size, as through the use of standard sonication andhomogenization techniques. Embodiments of liposomal formulationscontaining the pharmacological agent of interest may be lyophilized toproduce a lyophilizate which may be reconstituted with apharmaceutically acceptable carrier, such as water, to regenerate aliposomal suspension.

A pharmaceutical composition of the subject invention may optionallycontain, in addition to a pharmacological agent, at least one othertherapeutic agent useful in the treatment of a condition. Such othercompounds may be of any class of drug or pharmaceutical agent, includingbut not limited to antibiotics, anti-parasitic agents, antifungalagents, anti-viral agents, anti-tumor agents, anti-neurodegenerativeagents and anti-psychotic agents. When administered with anti-parasitic,anti-bacterial, anti-fungal, anti-tumor, anti-viral agents,anti-neurodegenerative, and anti-psychotic agents and the like,pharmacological agents may be administered by any method and route ofadministration suitable to the treatment of the condition, typically aspharmaceutical compositions.

Pharmacological agents may include compositions that may be preparedfrom water-insoluble compounds, or salts thereof, such as aqueous baseemulsions. In such embodiments, the pharmacological agent compositionwill typically contain a sufficient amount of pharmaceuticallyacceptable emulsifying agent to emulsify the desired amount of thepharmacological agent. Useful emulsifying agents include, but are notlimited to, phosphatidyl cholines, lecithin, and the like.

As noted above, in addition to active pharmacological agents, thecompositions may contain other additives, such as pH-adjustingadditives. In particular, useful pH-adjusting agents include acids, suchas hydrochloric acid, bases or buffers, such as sodium lactate, sodiumacetate, sodium phosphate, sodium citrate, sodium borate, or sodiumgluconate. Furthermore, pharmacological agent compositions may, thoughnot always, contain microbial preservatives. Microbial preservativesthat may be employed include, but are not limited to, methylparaben,propylparaben, and benzyl alcohol. The microbial preservative may beemployed when the pharmacological agent formulation is placed in a vialdesigned for multi-dose use. Pharmacological agent compositions for usein practicing the subject methods may be lyophilized using techniqueswell known in the art.

The pharmaceutically acceptable excipients, such as vehicles, adjuvants,carriers or diluents, are readily available to the public. Moreover,pharmaceutically acceptable auxiliary substances, such as pH adjustingand buffering agents, tonicity adjusting agents, stabilizers, wettingagents and the like, are readily available to the public.

Embodiments may also include administration of at least onepharmacological agent using a pharmacological delivery device such as,but not limited to, pumps (implantable or external devices), epiduralinjectors, syringes or other injection apparatus, catheter and/orreservoir operatively associated with a catheter, etc. For example, incertain embodiments a delivery device employed to deliver at least onepharmacological agent to a subject may be a pump, syringe, catheter orreservoir operably associated with a connecting device such as acatheter, tubing, or the like. Containers suitable for delivery of atleast one pharmacological agent to a pharmacological agentadministration device include instruments of containment that may beused to deliver, place, attach, and/or insert at least onepharmacological agent into the delivery device for administration of thepharmacological agent to a subject and include, but are not limited to,vials, ampules, tubes, capsules, bottles, syringes and bags.

In certain embodiments, a pharmaceutically acceptable carrier may bepreservative free. By “preservative free” is meant the substantialabsence of chemical, antibacterial, antimicrobial, or antioxidativeadditives, or the like, from the pharmaceutically acceptable carriers ofthe present invention. “Substantial absence” may mean that nopreservative is present in the compositions or that trace amounts may bepresent that impart no detectable effect otherwise attributable to apreservative. For example, the pharmaceutically acceptable carrier maybe characterized by the substantial absence of chemical, antibacterial,antimicrobial, or antioxidative additives or the like (e.g., containless than about 5.0, 4.0, 3.0, 2.0, 1.0, 0.5, 0.1, 0.05, 0.01, or evenabout 0.00 percent by weight of a preservative). Further, suchformulations may be substantially or essentially free of alcohols suchas ethanol (e.g., contain less than about 5.0, 4.0, 3.0, 2.0, 1.0, 0.5,0.1, 0.05, 0.01, or even about 0.00 percent by weight of alcohols suchas ethanol). Examples of suitable pharmacological agent formulationsinclude, but are not limited to, formulations that include one or moreactive pharmacological agents and physiological saline solution(optionally including other typical ingredients such as other activeagents and buffers).

As noted above, in pharmaceutical dosage forms, agents may beadministered alone or with an appropriate association, as well as incombination, with other pharmaceutically active compounds. As usedherein, “administered with” means that at least one pharmacologicalagent and at least one other adjuvant (including one or more otherpharmacological agents) are administered at times sufficiently closethat the results observed are indistinguishable from those achieved whenone pharmacological agent and at least one other adjuvant (including oneor more other pharmacological agents) are administered at the same pointin time. The pharmacological agent and at least one other adjuvant maybe administered simultaneously (i.e., concurrently) or sequentially.Simultaneous administration may be carried out by mixing at least onepharmacological agent and at least one other adjuvant prior toadministration, or by administering the pharmacological agent and atleast one other adjuvant at the same point in time. Such administrationmay be at different anatomic sites or using different routes ofadministration. The phrases “concurrent administration,” “administrationin combination,” “simultaneous administration” or “administeredsimultaneously” may also be used interchangeably and mean that at leastone pharmacological agent and at least one other adjuvant areadministered at the same point in time or immediately following oneanother. In the latter case, the at least one pharmacological agent andat least one other adjuvant are administered at times sufficiently closethat the results produced are synergistic and/or are indistinguishablefrom those achieved when the at least one pharmacological agent and atleast one other adjuvant are administered at the same point in time.Alternatively, a pharmacological agent may be administered separatelyfrom the administration of an adjuvant, which may result in asynergistic effect or a separate effect. The methods and excipientsdescribed herein are merely exemplary and are in no way limiting.

Unit dosage forms for oral or rectal administration such as syrups,elixirs, and suspensions may be provided wherein each dosage unit, forexample, teaspoonful, tablespoonful, tablet or suppository, contains apredetermined amount of a pharmacological agent. Similarly, unit dosageforms for injection or intravenous or other suitable administrationroute may include the pharmacological agent(s) in a composition as asolution in sterile water, normal saline or another pharmaceuticallyacceptable carrier.

The term “unit dosage form,” as used herein, refers to physicallydiscrete units suitable as unitary dosages for human and animalsubjects, each unit containing a predetermined quantity ofpharmacological agent calculated in an amount sufficient to produce thedesired effect in association with a pharmaceutically acceptablediluent, carrier or vehicle. The specifications for the unit dosageforms of pharmacological agents of the present invention depend on, forexample, the particular pharmacological agent(s) employed and the effectto be achieved, the pharmacodynamics associated with the particularpharmacological agent(s) in the subject, etc.

Embodiments include administering an effective amount of a first agentand an effective amount of a second agent. For example, embodiments mayinclude administering a first agent and a second agent to provide anenhanced therapeutic effect. By “enhanced therapeutic effect” is meantthat at least the desired outcome occurs more quickly and/or is ofgreater magnitude with a combination of the pharmacological agents, ascompared to the same doses of each component given alone; or that dosesof one or all component(s) are below what would otherwise be a minimumeffective dose (a “sub-MED”).

Any two pharmacological agents may be given in close enough temporalproximity to allow their individual therapeutic effects to overlap. Forexample, embodiments of the subject invention include the co-timelyadministration of a first and second agent, where “co-timely” is meantadministration of a second pharmacological agent while a firstpharmacological agent is still present in a subject in a therapeuticallyeffective amount. It is to be understood that in some instances thiswill require sequential administration. Alternatively, multiple routesof administration may be employed, e.g., intravenous or subcutaneousinjection combined with oral administration, and the like.

Embodiments also include pharmaceutical compositions in unit dosageforms that are useful which contain more than one type ofpharmacological agent. In other words, a single agent administrationentity may include two or more pharmacological agents. For example, asingle tablet, capsule, dragee, trocheem suppository, syringe, and thelike, combining two or more pharmacological agents would be a unitdosage form. The therapeutic agents present in a unit dosage form may bepresent in amounts such that, upon administration of one or more unitdoses of the composition, a subject experiences, e.g., a longer lastingefficacy than with the administration of either agent alone and/orgreater magnitude and/or quicker lowering of action. Such compositionsmay be included as part of a therapeutic package in which one or moreunit doses are placed in a finished pharmaceutical container. Labelingmay be included to provide directions for using the compositionaccording to the invention. The actual amounts of each agent in suchsingle unit dosage forms may vary according to the specific compositionsbeing utilized, the particular compositions formulated, the mode ofapplication, the particular route of administration, and the like, wheredosages for a given subject may be determined using conventionalconsiderations, e.g., by customary comparison of the differentialactivities of the subject compositions and of a known agent, or by meansof an appropriate, conventional pharmacological protocol.

Applying Electrical Energy

As noted above, certain embodiments include employing electricalmodulation, in a manner effective to cause the desired enhancementaccording to the subject methods.

Any suitable area may be targeted for electrical modulation. Areas thatmay be targeted include, but are not limited to, pre- and postganglionic nerve fibers, as well as ganglionic structures, efferent andafferent nerve fibers, synapses, etc., and combinations thereof incertain embodiments. In certain embodiments, activity in a given nervefiber may be electrically modulated in more than one area of the nervefiber. In certain embodiments, electrical energy is applied to modulatesynaptic efficiency, e.g., to increase or decrease the sensitivity of asynapse and include modulating presynaptic neurons.

As such, areas which may be targeted with electrical energy include, butare not limited to, pre- and post ganglionic nerve fibers, ganglionicstructures, efferent and afferent nerve fibers, the hypothalamus,receptors any receptor described herein, afferent autonomic nerves(sympathetic and parasympathetic). Embodiments include receptors of thehypothalamus, including hormonal receptors on the hypothalamus. Incertain embodiments, a given nerve fiber or the like may be targeted forelectrical modulation in more than one area of the nerve fiber. Targetedareas of the nervous system which may be targeted in accordance with thesubject invention include, but are not limited to, vagus nerve, opticganglion, and sphenopalatine ganglion, internal carotid nerve andplexus, middle and superior cervical sympathetic ganglion; vertebralganglion; cervicothoracic ganglion; sympathetic trunk; cervical cardiacnerves; cardiac plexus; thoracic aortic plexus; celiac ganglion; celiactrunk and plexus; superior mesenteric ganglion; superior mesentericartery and plexus; intermesenteric plexus; inferior mesenteric ganglion;inferior mesenteric artery and plexus; superior hypogastric plexus;hypogastric nerves; vesical plexus; thoracic cardiac nerves; sympathetictrunk; 6th thoracic sympathetic ganglion; gray and white ramicommunicantes; greater, lesser and least splanchnic nerves; aorticorenalganglion; lumbar splanchnic nerves; gray rami communicantes and sacralsplanchnic nerves; and the like, or a combination of two or more of theabove.

A number of different devices may be employed in accordance with thesubject invention. For example, device and systems for applyingelectrical energy to a subject and which may be adapted for use in thesubject invention are described, e.g., in copending U.S. patentapplication Ser. Nos. 10/661,368, 10/871,366 and elsewhere, thedisclosures of the US patent applications are herein incorporated byreference. Such devices may be positioned directly on a targeted area,e.g., positioned below the skin of a subject directly on or adjacent aportion of the nervous system (e.g., one or more nerve fibers) such asan implantable device, or may be an external device (i.e., some or allof the device may be external to the subject). In accordance with thesubject invention, one or more electrodes or electrical contacts may bepositioned directly on or adjacent a targeted area, where the one ormore electrodes may be surgically implanted, e.g., directly on oradjacent a targeted nerve fiber of a subject. In certain embodiments, animmunomodulator such as a steroid or the like, may be incorporated intoa surface contacting area of a device, e.g., to minimize inflammation ofthe targeted site.

An electric energy applying device typically includes a stimulator suchas an electrode, a controller or programmer and one or more connectorsfor connecting the stimulating device to the controller. In certainembodiments more than one electrode may be employed. In furtherdescribing representative electrodes, such are described in thesingular, but it will be apparent that more than one electrode may beused, where such may be the same or may be different in one or moreaspects. Accordingly, the description of an exemplary electrode suitablefor use in the subject methods is applicable to other electrodes thatmay be employed.

The electrode employed in the subject invention is controllable toprovide output signals that may be varied in voltage, frequency, pulsewidth, current and intensity. The electrode may be one that providesboth positive and negative current flow from the electrode and/or may becapable of stopping current flow from the electrode and/or changing thedirection of current flow from the electrode. For example, embodimentsinclude an electrode that is controllable in these respects, i.e.,controllable in regards to producing positive and negative current flowfrom the electrode, stop current flow from the electrode, changedirection of current flow from the electrode, and the like. In certainembodiments, the electrode has the capacity for variable output, linearoutput and short pulse width.

The energy source for the electrical output may be provided by a batteryor generator such as a pulse generator that is operatively connected tothe electrode. The energy source may be positioned in any suitablelocation such as adjacent to the electrode (e.g., implanted adjacent theelectrode), or a remote site in or on the subject's body or away fromthe subject's body in a remote location and the electrode may then beconnected to the remotely positioned energy source using wires, e.g.,may be implanted at a site remote from the electrode or positionedoutside the subject's body in certain instances. Of interest areimplantable generators analogous to a cardiac pacemaker.

The electrode may be mono-polar, bipolar or multi-polar. In order tominimize the risk of an immune response triggered by the subject againstthe device and minimize damage such as corrosion and the like to thedevice from other biological fluids, etc., the electrode and any wiresand optional housing materials are made of inert materials such as forexample silicon, metal, plastic and the like. For example, a multi-polarelectrode having about four exposed contacts (e.g., cylindrical contactsmay be employed).

A controller or programmer may also be coupled with an electric energyapplying device. The programmer is typically one or more microprocessorsunder the control of a suitable software program. Other components ofthe programmer will be apparent to those of skill in the art, e.g.,analog to digital converter, etc. The electric energy applying devicemay be pre-programmed for desired parameters. In certain embodiments theparameters are controllable such that the electrode signal may beremotely modulated to desired settings without removal of the electrodefrom its targeted position. Remote control may be performed, e.g., usingconventional telemetry with an implanted electric signal generator andbattery, an implanted radiofrequency receiver coupled to an externaltransmitter, and the like. In certain embodiments, some or allparameters of the electrode may be controllable by the subject, e.g.,without supervision by a physician. For example, a magnetic signal maybe employed. In such embodiments, one or more magnets may be employedsuch that upon bringing a magnet in proximity to or away from the powersource such as a pulse generator, the magnet may be employed tointerfere with the electronic circuitry thus modulating the power—eitherincreasing or decreasing the power supplied depending on whether themagnet is brought in proximity or moved away from the power source.

FIG. 1 shows an exemplary embodiment of an electric energy applyingdevice 100. Device 100 may be implanted in a suitable position of asubject's body 10. One or more leads 23 are shown positioned tostimulatory or inhibitory electrical energy. Device 100 include energysource 14 which may take the form of a modified signal generator, Model7424 manufactured by Medtronic, Inc. under the trademark Intrel II. Lead23 may take the form of any suitable lead, such as any of the leads thatare sold with the Model 7427 and is coupled to energy source 14 by oneor more conventional conductors 16 and 18. Lead 23 may include a paddlelead, a lead having one or more electrodes and/or catheters, or acombination catheter/lead capable of providing electrical impulses andpharmacological delivery. In certain embodiments, a lead may be composedof concentric tubes such as made of platinum or other like material. Thetubes may be coated with a polymer except for the distal portions thatmay serve as the electrodes. Conductive wires carrying energy to theelectrodes may be in the interior of the concentric tubes. Optionally, adistal electrode end may include a small recording microelectrode tohelp assist in the actual placement of the lead.

The present invention may be operated as an open-loop controlled system.In an open-loop system, the physician or patient may at any timemanually or by the use of pumps or motorized elements adjust treatmentparameters such as pulse amplitude, pulse width, pulse frequency, orduty cycle. Optionally, the present invention may incorporate aclosed-loop control system which may automatically adjust the electricalparameters in response to a sensed parameter or condition of a subject.Under a closed-loop feedback system to provide automatic adjustment ofparameters of the electrodes, a sensor that senses a condition of thebody is utilized. More detailed descriptions of sensors that may beemployed in the practice of the subject invention, and other examples ofsensors and feedback control techniques that may be employed aredisclosed in U.S. Pat. No. 5,716,377, which is incorporated herein byreference.

As shown in FIG. 1 , the distal end of lead 23 terminates in one or moredelivery elements such as stimulation electrodes which may be implantedusing conventional surgical techniques. The type of treatment that isdesired determines the location of the electrodes. Any number ofelectrodes may be used for various applications. Each of the electrodesmay be individually connected to energy source 14 through lead 23 andconductors 16 and 18. Lead 23 may be surgically implanted either by alaminotomy or by a needle.

Energy source or signal generator 14 may be programmed to provide apredetermined stimulation (or inhibition) dosage in terms of pulseamplitude, pulse width, pulse frequency, or duty cycle. As shown, aprogrammer 20 may be utilized to provide stimulation (or inhibition)parameters to the delivery device via any suitable technology, e.g.,using telemetry and the like. For example, in using telemetry,programmer 20 may be coupled to an antenna 24 via conductor 22. Incertain embodiments, the programmer may be positioned, e.g., implanted,inside body 10. For example, in certain embodiments the programmer maybe integrated with the energy source, electrode, etc., for example as asingle unit.

Device 100 may optionally include one or more sensors to provideclosed-loop feedback control of the treatment and/or electrodepositioning. One or more sensors (not shown) may be attached to orimplanted into a portion of a subject's body suitable for detecting aphysical and/or chemical indicator of the subject. For example, sensingfeedback may be accomplished, e.g., by a mechanical measure within alead or an ultrasound or other sensor to provide information about thetreatment parameters, lead positioning, LTP, etc.

Operative placement of a suitable electric energy applying device may beaccomplished using any suitable technique. An electrode introducerneedle may be employed to implant the electrode on or proximate to thearea of interest. The size of the introducer needle may vary dependingon the diameter of the electrode, etc., where in certain embodiments theelectrode introducer needle may be a 12-gauge, 14-gauge, 16-gauge,18-gauge, 20-gauge needle or 22-gauge needle, e.g., an electrodeintroducer needle available from Radionics in the Sluyter-Mehta kit asSMK 100 mm 2 mm active tip cannula. However, it should be understoodthat other electrode introducer needles may be used as appropriate tothe needs and skill level of the practitioner performing the surgicalprocedure.

At least one imaging apparatus such as a CT scan, MRI apparatus,ultrasound apparatus, fluoroscope, or the like, may be employed tomonitor the surgical. For exemplary purposes only, the subject methodwill be described using a fluoroscope, where such is in no way intendedto limit the scope of the invention. The subject is placed in a suitableposition for access e.g., supine, on a fluoroscopy table, with thepatient's nose pointing vertically. The fluoroscope is then adjusted toa straight lateral position. And the entry point for the insertion ofthe electrode is determined.

Once the entry point is determined, the skin overlying the entry pointis shaved and prepared with antiseptic solution. A 25-gauge needle maybe used to inject a subcutaneous local anesthetic (such as, for example,2 cc of 2% lidocaine) into the skin and subcutaneous tissues overlyingthe entry point. In addition to the local anesthetic, the patient may begiven intravenous sedation and prophylactic antibiotics prior tocommencement of the implantation procedure if desired.

The electrode introducer needle is inserted at the entry point andadvanced. The fluoroscope may be adjusted as the needle is advanced.Once the needle is positioned the stylet is withdrawn from the electrodeintroducer needle. Once the implanted electrode is in place, the end ofthe electrode that is outside the skin is carefully held in placeagainst the skin. The electrode introducer needle may then be slowlyremoved, leaving the implanted electrode in place. At this point, ifdesired, a few small subcutaneous sutures may be placed around theelectrode to hold it in the desired position.

Once the needle has been completely removed and the implanted electrodeis in the final position, then the proximal part of the electrode thatis coming out of the skin may be secured to the skin of the subject,e.g., by adhesive tape. Additionally, a small incision may be made onthe skin at the area the electrode exits the face. Then severalsubcutaneous sutures may be placed around the electrode to hold it inplace. The distal end of the electrode may then be connected to anextension wire or catheter, which is tunneled to the subclavicular area,or another region which will house the device used as an energy sourcefor the implanted electrode. The device or devices used to control theelectrode may be surgically implanted in the desired region byprocedures known in the art, such as have been applied in surgicalneuromodulation therapies used to treat Parkinson's disease.

In certain embodiments of the subject invention, an electrode may beutilized which, instead of or in addition to delivering electricimpulses to at least a portion of the autonomic nervous system, deliversa pharmacological agent to at least a portion of the autonomic nervoussystem. For example, an electrode may be used that has a small port atits tip which is connected to a reservoir or pump containing apharmacological agent. The pharmacological agent delivery electrode maybe implanted using an analogous procedure as that described above forthe autonomic system modulating-electrode. In certain embodiments thereservoir or pump may also be implanted in the subject's body, analogousto that described above for the electrical impulse generator. Thepharmacological agent delivery electrode may be controllable such thatthe amount of pharmacological agent delivered, the rate at which thepharmacological agent may be delivered, and the time period over whichthe pharmacological agent is delivered may be adjusted.

In embodiments in which electrical energy is used, any suitable protocolmay be used, where certain protocols include using an electric energyapplying device to deliver a suitable amount of electrical energy to asubject. Once an electric energy applying device is positioned in asuitable position on or about one or more targeted areas electricalenergy is applied thereto for a period of time sufficient to provide thedesired effect. This period of time will vary depending on the area(e.g., the nerve fiber) being treated, the condition being treated, etc.Certain embodiments include simultaneously monitoring (i.e., in “realtime”) the aspect of the nervous system such that a given nerve fibermay be electrically stimulated (or electrically inhibited) until thedesired result is observed. Still further, in many embodiments once thedesired result is achieved, a targeted area may be repeatedlyelectrically stimulated (or inhibited) one or more times to maintain thedesired state such that the subject methods may be repeated one or moretimes, i.e., the subject methods include chronically applying electricalenergy to a subject, such as chronically applying electrical energy toone or more nerve fibers. For example, in certain embodiments electricalstimulation (e.g., intermittent mild electrical pulses) may be deliveredto a given area of the nervous system, twenty-four hours a day for aperiod of days, weeks, months, or even years in certain embodiments.

During the period of time that electrical energy is applied to a givenarea, the electrical energy may be substantially continuous, includingcontinuous or intermittent (i.e., pulsed or periodic), where in manyembodiments the electrical energy is in the form of electrical pulses.In other words, in certain embodiments electrical energy may be givencontinuously during the above-described period of time and in certainembodiments electrical energy may be given to an area in a pulsed orintermittent manner during the period of time described above.

In accordance with the subject methods to apply electrical energy to asubject, once operatively positioned the electric energy applying deviceis activated to provide an electrical signal to the targeted area in amanner effective to practice the subject methods.

In practicing the subject methods, activation of the electric energyapplying device directly applies the electrical output of the device,i.e., electrical impulses, to the targeted area. The exact parameters ofthe applied electrical energy may vary depending on the particularsubject, condition being treated, etc. For example, an electroniccurrent wave may be provided when the electrical energy is applied. Incertain embodiments, the current wave includes current waves of highfrequency, e.g., high frequency pulses, where the current wave may alsoinclude low frequency amplitude modulation. In certain embodiments, aplurality of high frequency bursts of current pulses may be applied inaddition to the application of underlying low frequency continuousstimulus. Stimulation may be monopolar or multipolar.

For example, to stimulate a targeted area, voltage or intensity mayrange from about 1 millivolt to about 1 volt or more, e.g., 0.1 volt toabout 50 volts, e.g., from about 0.2 volt to about 20 volts and thefrequency may range from about 1 Hz to about 2500 Hz, e.g., about 1 Hzto about 1000 Hz, e.g., from about 2 Hz to about 100 Hz in certainembodiments. In certain embodiments a pure d-c voltages may be employed.The pulse width may range from about 1 microsecond to about 2000microseconds or more, e.g., from about 10 microseconds to about 2000microseconds, e.g., from about 15 microseconds to about 1000microseconds, e.g., from about 25 microseconds to about 1000microseconds. The electrical output may be applied for at least about 1millisecond or more, e.g., about 1 second, e.g., about several seconds,where in certain embodiments the stimulation may be applied for as longas about 1 minute or more, e.g., about several minutes or more, e.g.,about 30 minutes or more may be used in certain embodiments.

In certain embodiments, a control feedback loop is provided. Forexample, during or following a particular electric energy applyingprotocol, a biological aspect of a subject may be monitored, e.g., bysensing conduction in a neuronal system, e.g., in a particularelectrically stimulated nerve fiber, or by any suitable method. Forexample, a sensor suitable for detecting nerve cell or axon activity maybe implanted in a portion of a subject's body. A sensor may take theform of an electrode or the like. Signals received by such a sensor maybe amplified before further processing. A sensor may also take the formof a device capable of detecting nerve compound action potentials or maytake the form of a transducer that includes an electrode with an ionselective coating applied which is capable of directly transducing theamount of a particular transmitter substance or its breakdownby-products. In utilizing a feedback system, if a predetermineddetection criteria is not detected the same or a different stimulusprotocol may be performed and may be automatically initiated under thecontrol of a controller. For example, in those instances where adifferent protocol is performed, one or more of the electrical energyapplying parameters may be modified, e.g., the pulse width may beincreased, or the like, in the second protocol.

Utility

The subject methods find use in a variety of applications, as reviewedabove. By treatment is meant that at least an amelioration of thesymptoms associated with the condition afflicting the host is achieved,where amelioration is used in a broad sense to refer to at least areduction in the magnitude of a parameter, e.g. symptom, associated withthe condition being treated. As such, treatment also includes situationswhere the pathological condition, or at least symptoms associatedtherewith, are completely inhibited, e.g. prevented from happening, orstopped, e.g. terminated, such that the host no longer suffers from thecondition, or at least the symptoms that characterize the condition.

A variety of hosts are treatable according to the subject methods. Incertain embodiments, such hosts are “mammals” or “mammalian,” wherethese terms are used broadly to describe organisms which are within theclass mammalia, including the orders carnivore (e.g., dogs and cats),rodentia (e.g., mice, guinea pigs, and rats), and primates (e.g.,humans, chimpanzees, and monkeys). In many embodiments, the hosts willbe humans.

As indicated above, the subject methods may be used in the treatment ofa variety of different disease conditions, including, but not limitedto: cardiovascular diseases, such as atherosclerosis, coronary arterydisease, hypertension, hyperlipidemia, eclampsia, pre-eclampsia,cardiomyopathy, volume retention, congestive heart failure, QT intervalprolongation, aortic dissection, aortic aneurysm, arterial aneurysm,arterial vasospasm, myocardial infarction, reperfusion syndrome,ischemia, sudden adult death syndrome, fatal arrythmias, coronarysyndromes, coronary vasospasm, sick sinus syndrome, bradycardia,tachycardia, arrhythmias, thromboembolic disease, deep vein thrombosis,coagulopathy, DIC, mesenteric ischemia, syncope, venous thrombosis,arterial thrombosis, malignant hypertension, secondary hypertension,primary pulmonary hypertension, secondary pulmonary hypertension,Raynaud's, paroxysmal supraventricular tachycardia, and the like;neurodegenerative diseases, such as Alzheimer's, Pick's, Parkinson's,amyotrophic lateral sclerosis, neuroinflammatory diseases, viralmeningitis, viral encephalitis, fungal meningitis, fungal encephalitis,multiple sclerosis, charcot joint, schizophrenia, and the like;orthopedic inflammatory diseases, such as osteoarthritis, reflexsympathetic dystrophy, osteoporosis, regional idiopathic osteoporosis,Paget's disease, juvenile chronic arthritis, antigen-induced arthritis,and the like; inflammatory conditions, such as ARDS, multiple sclerosis,rheumatoid arthritis, migraines, chronic headaches, and the like;lymphoproliferative diseases, such as lymphoma, lymphoproliferativedisease, Hodgkin's disease, inflammatory pseudotumor of the liver, andthe like; autoimmune diseases, such as Graves disease, Hashimoto's,Takayasu's disease, Kawasaki's disease, arteritis, scleroderma, CRESTsyndrome, allergies, dermatitis, Henoch-Schlonlein purpura, goodpasturesyndrome, autoimmune thyroiditis, myasthenia gravis, lupus, Reiter'ssyndrome and the like; inflammatory and infectious diseases, such assepsis, diseases of wound healing, viral infections, wound healing,tuberculosis, infection, fungal infections, AIDS, human immunodeficiencyvirus and the like; pulmonary diseases, such as tachypnea, fibrotic lungdiseases, cystic fibrosis, interstitial lung disease, desquamativeinterstitial pneumonitis, non-specific interstitial pneumonitis,lymphocytic interstitial pneumonitis, usual interstitial pneumonitis,idiopathic pulmonary fibrosis, pulmonary edema, aspiration,asphyxiation, pneumothorax, right-to-left shunts, left-to-right shunts,respiratory failure, and the like, gastrointestinal disorders, such ashepatitis, xerostomia, bowel mobility, constipation, irritable bowelsyndrome, peptic ulcer disease, ileus, post-operative bowel dysmotility,inflammatory bowel disease, typhlitis, cholelethiasis, cholestasis,fecal incontinence, cyclic vomiting syndrome,diverticulitis/diverticulosis, and the like; endocrine disorders, suchas hypothyroidism, diabetes, obesity, syndrome X, hyperglycemia, insulinresistance, PCOS, and the like; genitourinary disorders, such as bladderdysfunction, renal failure, erectile dysfunction, hyperreninemia,hepatorenal syndrome, pulmonary renal syndrome, incontinence, arousaldisorders, menopausal mood disorders, premenstrual mood disorders, andthe like; skin disorders, such as wrinkles, cutaneous vasculitis, andthe like; aging associated diseases and conditions, such as shy dragers,multi-symptom atrophy, age related inflammation conditions, cancer,aging and the like; Th-2 dominant, such as diseases typhlitis,osteoporosis, lymphoma, myasthenia gravis, lupus and the like;conditions that cause hypoxia, hypercarbia, and/or acidosis, such asCOPD, emphysema, any chronic lung disease that causes acidosis, suddeninfant death syndrome, sudden adult death syndrome, acute pulmonaryembolism, chronic pulmonary embolism, pleural effusion, cardiogenicpulmonary edema, non-cardiogenic pulmonary edema, acute respiratorydistress syndrome (“ARDS”), neurogenic edema, acidosis of anycausehypercapnia, acidemia, renal tubular acidosis, asthma, any chroniclung disease that causes hypoxia or hypercarbia or hypercapnia, and thelike; Neurologic diseases, such as epilepsy, seizures, stroke, insomnia,sleep disorders, cerebral vascular accident, transient ischemic attacks,headaches, concussions, post-concussive syndrome, cerebral vascular,vasospasm, central sleep apnea, obstructive sleep apnea, stress, bipolardisorder, migraines, chronic headaches, ADEM, depression, and the like;pediatric conditions, e.g., respiratory distress syndrome, sudden infantdeath syndrome, Hirschsprung's disease, bronchopulmonary dysplasia,congenital megacolon, aganglionosis, juvenile rheumatoid arthritis,juvenile chronic arthritis and the like; OB-GYN diseases, e.g., amnioticfluid embolism, pregnancy-related arrhythmias, fetal stress, fetalhypoxia, amniotic fluid embolism, gestational diabetes, pre-term labor,cervical incompetence, fetal distress, peri-partum maternal mortality,labor complications, premenstrual syndrome, dysmenorrhea, endometriosis,and the like; as well as other conditions, including but not limited to:chronic pain, glaucoma, trauma, hospitalization, post-operativerecovery, post-procedural recovery, transplant-related side effects,fibrosis, transplant-related tachycardia, transplant rejection,transplant-related bowel dysmotility, transplant-related hyperreninemia,male infertility, disorders of thermoregulation, fibromyalgia, and thelike; menstrual related disorders, e.g., pelvic pain, dysmenorrhea, gidisease, nausea, etc.; peripartum and pregnancy related disorders;peripartum cardiomyopathy; sickle cell disease; reperfusion injury;central serous choroidoretinopathy; stress; post traumatic stressdisorder; gulf war syndrome; etc.

Computer Readable Mediums and Programming Stored Thereon

The subject invention includes computer readable media havingprogramming stored thereon for implementing the subject methods. Forexample, the subject invention may include suitable computing means suchas suitable hardware/software for performing the subject methods.

In certain embodiments, programming may control a device to administer apharmacological agent to a subject, e.g., programming may be configuredto determine suitable dosage, etc. In certain embodiments programmingmay control a device to administer electrical energy to a subject, e.g.,may control the activation/termination of electrical energy includingselecting suitable electrical parameters. Programming may be configuredto, or otherwise be capable of, directing a microprocessor to activate,i.e., turn “on” and “off” an electric energy applying device forapplying energy to a subject. For example, if so determined, theprocessor may direct the electric energy applying device to provide theappropriate energy to result in the desired action. Accordingly, aprocessor may select the appropriate parameters (e.g., frequency,amplitude, etc.) depending on what is required and direct an electricenergy applying device to implement the parameters.

Programming according to the subject invention may be recorded oncomputer-readable media, e.g., any medium that can be read and accesseddirectly or indirectly by a computer. Such media include, but are notlimited to, computer disk or CD, a floppy disc, a magnetic “hard card”,a server, magnetic tape, optical storage such as CD-ROM and DVD,electrical storage media such as RAM and ROM, and the hybrids of thesecategories such as magnetic/optical storage media. One of skill in theart can readily appreciate how any of the presently known computerreadable mediums may be used to provide a manufacture that includes arecording of the present programming/algorithm for carrying out theabove-described methodology. Thus, the computer readable media may be,for example, in the form of any of the above-described media or anyother computer readable media capable of containing programming, storedelectronically, magnetically, optically or by other means. As such,stored programming embodying steps for carrying-out some or all of thesubject methods may be transferred to a computer-operated apparatus suchas a personal computer (PC) or the like, by physical transfer of a CD,floppy disk, or like medium, or may be transferred using a computernetwork, server, or other interface connection, e.g., the Internet.

For example, the subject invention may include a computer readablemedium that includes stored programming embodying an algorithm forcarrying out the subject methods, where such an algorithm is used todirect a processor or series of processors to execute the stepsnecessary to perform the task(s) required of it and as such in certainembodiments the subject invention includes a computer-based system forcarrying-out some or all of the subject methods. For example, such astored algorithm may be configured to, or otherwise be capable of,directing a microprocessor to receive information directly or indirectlyfrom data gathering means and process that information to determine ifintervention is required. The result of that processing may becommunicated to a user, e.g., via audio and/or visual means, e.g., thealgorithm may also include steps or functions for generating a varietyof profile graphs, plots, etc.

The subject invention may also include a data set of known or referenceinformation stored on a computer readable medium to which data collectedmay be compared for use in determining a given treatment regimen. Thedata may be stored or configured in a variety of arrangements known tothose of skill in the art.

Kits

Also provided are kits for practicing the subject methods. Kits mayinclude an electric energy applying device, as described above. Devicesfor delivering, e.g., implanting, an electric energy applying device toa target site of a subject such as into the body cavity of a subject mayalso be included in the subject kits. For example, an endoscope,introducer needle, and the like may be provided. The subject kits mayalso include one or more pharmacological agents, as described above. Thedosage amount of the one or more pharmacological agents provided in akit may be sufficient for a single application or for multipleapplications. Accordingly, in certain embodiments of the subject kits asingle dosage amount of a pharmacological agent is present and incertain other embodiments multiple dosage amounts of a pharmacologicalagent may be present in a kit. In those embodiments having multipledosage amounts of pharmacological agent, such may be packaged in asingle container, e.g., a single tube, bottle, vial, and the like, orone or more dosage amounts may be individually packaged such thatcertain kits may have more than one container of a pharmacologicalagent.

Suitable means for delivering one or more pharmacological agents to asubject may also be provided in a subject kit. The particular deliverymeans provided in a kit is dictated by the particular pharmacologicalagent employed, as describe above, e.g., the particular form of theagent such as whether the pharmacological agent is formulated intopreparations in solid, semi-solid, liquid or gaseous forms, such astablets, capsules, powders, granules, ointments, solutions,suppositories, injections, inhalants and aerosols, and the like, and theparticular mode of administration of the agent, e.g., whether oral,buccal, rectal, parenteral, intraperitoneal, intradermal, transdermal,intracheal, etc. Accordingly, certain systems may include a suppositoryapplicator, syringe, I.V. bag and tubing, electrode, etc.

The subject kits may also include instructions for how to practice thesubject methods using the components of the kit. The instructions may berecorded on a suitable recording medium or substrate. For example, theinstructions may be printed on a substrate, such as paper or plastic,etc. As such, the instructions may be present in the kits as a packageinsert, in the labeling of the container of the kit or componentsthereof (i.e., associated with the packaging or sub-packaging) etc. Inother embodiments, the instructions are present as an electronic storagedata file present on a suitable computer readable storage medium, e.g.CD-ROM, diskette, etc. In yet other embodiments, the actual instructionsare not present in the kit, but means for obtaining the instructionsfrom a remote source, e.g. via the internet, are provided. An example ofthis embodiment is a kit that includes a web address where theinstructions can be viewed and/or from which the instructions can bedownloaded. As with the instructions, this means for obtaining theinstructions is recorded on a suitable substrate.

Some or all components of the subject kits may be packaged in suitablepackaging to maintain sterility. In many embodiments of the subjectkits, the components of the kit are packaged in a kit containmentelement to make a single, easily handled unit, where the kit containmentelement, e.g., box or analogous structure, may or may not be an airtightcontainer, e.g., to further preserve the sterility of some or all of thecomponents of the kit.

Representative Embodiments

In further describing the subject invention, a number of representativeembodiments are described below in greater detail.

Implantable Drug Delivery Devices

In one representative embodiment, the subject methods include applying apharmacological stimulus from an implantable drug delivery device in amanner effective to provide for the desired compensatory response in thesubject. A feature of certain of these embodiments is that theimplantable device delivers drug in a manner effective to cause thesubject in which the device is implanted to mount the desiredcompensatory response, as described above. In certain embodiments, theimplantable devices deliver agent to the subject in which they areimplanted in a manner that is discontinuous or pulsed, so as to achievethe desired stimulus of limited temporal duration.

Any of a variety of controlled drug delivery devices can be used inthese embodiments of the present invention to accomplish delivery of adrug formulation according to the subject invention. In general, thedrug delivery device minimally comprises a controlled drug deliverydevice and, in one embodiment, further comprises a drug deliverycatheter, e.g., where the implantation site is distant from the deliverysite.

Drug delivery devices suitable for use with the present invention cantake advantage of any of a variety of controlled drug release devices.In general, the drug release devices suitable for use in the inventioncomprise a drug reservoir for retaining a drug formulation oralternatively some substrate or matrix which can hold drug (e.g.,polymer, binding solid, etc.). The drug release device can be selectedfrom any of a variety of implantable controlled drug delivery systemknown in the art. Controlled drug release devices suitable for use inthe present invention generally can provide for delivery of the drugfrom the device at a selected or otherwise patterned amount and/or rateto a selected site in the subject.

In representative embodiments, implantable infusion devices include agenerally disc-shaped housing having a diameter dimension and athickness dimension. The thickness dimension of the device is dependent,at least in part, upon the relative placement of device components andthe thickness dimensions of the device components. Such devicestypically include a reservoir located within the housing for holding avolume of an infusion medium, for example, a liquid medication. Suchdevices also typically include an inlet for receiving infusion mediuminto the reservoir to fill or re-fill the reservoir, for example, from ahollow needle, such as a syringe needle.

In addition, implantable infusion devices may include a drivingmechanism, such as a pump, for controlling the flow of infusion mediumfrom the reservoir to the patient, through an outlet in the housing,either on a continuous basis, at scheduled or programmed times or inresponse to signals from a sensor or other signal source. Other devicesinclude pressurized gas sources for driving infusion medium from thereservoir. Each of those components define a thickness dimension which,depending upon their placement on the device, may affect the overallthickness dimension of the implantable infusion device.

Example implantable infusion devices are described in U.S. Pat. Nos.5,527,307, 5,514,103 and 5,176,644, each to Srisathapat et al. (andassigned to Minimed Technologies, Ltd.), U.S. Pat. No. 5,167,633 to Mannet al. (and assigned to Pacesetter Infusion, Ltd,), U.S. Pat. No.4,697,622 to Swift (assigned to Parker Hannifin Corporation) and U.S.Pat. No. 4,573,994 to Fischell et al. (assigned to The Johns HopkinsUniversity), each of which is incorporated herein by reference. Each ofthe above-cited patents describes an implantable infusion device whichincludes a generally disc-shaped housing containing a reservoir, adriving mechanism or pump, an inlet, an outlet and an electronic circuitfor controlling the operation of the driving mechanism or pump.

In certain embodiments, the infusion pump employed is part of a“closed-loop” system. The infusion pump system according to theseembodiments of the invention employs a pump for delivering measureddoses of an infusion formulation. In one embodiment, the pump comprisesan electromagnetic mechanism that is activated to selectively driveinfusion formulation to the user. The pump may be activated according toa programmed dispensing rate or schedule, or according to an actuationsignal from a sensing device, timer, manual operator or other suitablemeans. In certain embodiments, the pump may be activated by a controlsignal communicated to the pump from a computing element which may beincluded in the infusion pump system.

The infusion pump system according to these embodiments of the inventionfurther employs a sensing device for monitoring a selected biologicalstate.

The infusion pump system according to these embodiments of the inventionfurther employs a computing element which may, along with other pumpcontrol functions, execute a closed-loop algorithm which maycontinuously adjust infusion formulation delivery as a function of thesensed biological state. The computing element may comprise one or moreprogrammable processors, logic circuits, or other hardware, firmware orsoftware components configured for implementing the control functionsdescribed herein.

The infusion pump system according to certain embodiments of theinvention further employs a communication device for communicatinguser-initiated signals to the computing element. The user-initiatedsignals may be representative of events that affect the selectedbiological state. In one embodiment, the communication devicecommunicates with the computing element via a radio frequency (“RF”)transceiver. However, in other embodiments other suitable means of datacommunication may be employed, such as, for example, ultrasonics.

Representative closed-loop systems of interest are described in: U.S.Pat. Nos. 6,827,702; 6,740,072 and 6,558,351; the disclosures of whichare herein incorporated by reference.

In some embodiments, the delivery device is one that is adapted fordelivery of an agent over extended periods of time, such asdiscontinuously over extended periods of time. Such delivery devices maybe adapted for administration of an agent for several hours (e.g., 2hours, 12 hours, or 24 hours to 48 hours or more), to several days(e.g., 2 to 5 days or more, from about 100 days or more) to severalmonths or years, with intermissions of non-delivery, e.g., referred toas holiday periods above. As such, the devices are configured to delivera discontinuous or pulsed delivery of an agent over an extended periodof time, where the pulsed delivery may in certain embodiments, becharacterized as “irregularly irregular” as described above.

Release of drug from the device, particularly controlled release ofdrug, can be accomplished in any of a variety of ways according tomethods well known in the art, e.g., by incorporation of drug into apolymer that provides for substantially controlled diffusion of drugfrom within the polymer, incorporation of drug in a biodegradablepolymer, providing for delivery of drug from an osmotically-drivendevice, etc. Where the drug delivery device comprises a drug deliverycatheter, drug can be delivered through the drug delivery catheter tothe delivery site as a result of capillary action, as a result ofpressure generated from the drug release device, by diffusion, byelectrodiffusion or by electroosmosis through the device and/or thecatheter.

The drug delivery device must be capable of carrying the drugformulation in such quantities and concentration as therapeuticallyrequired, and must provide sufficient protection to the formulation fromattack by body processes for the duration of implantation and delivery.The exterior is thus preferably made of a material that has propertiesto diminish the risk of leakage, cracking, breakage, or distortion so asto prevent expelling of its contents in an uncontrolled manner understresses it would be subjected to during use, e.g., due to physicalforces exerted upon the drug release device as a result of movement bythe subject or physical forces associated with pressure generated withinthe reservoir associated with drug delivery. The drug reservoir or othermeans for holding or containing the drug must also be of such materialas to avoid unintended reactions with the active agent formulation, andis preferably biocompatible (e.g., where the device is implanted, it issubstantially non-reactive with respect to a subject's body or bodyfluids).

Suitable materials for the reservoir or drug holding for use in thedelivery devices of the invention are well known in the art. Forexample, the reservoir material may comprise a non-reactive polymer or abiocompatible metal or alloy. Suitable polymers include, but are notnecessarily limited to, acrylonitrile polymers such asacrylonitrile-butadiene-styrene polymer, and the like; halogenatedpolymers such as polytetrafluoroethylene, polyurethane,polychlorotrifluoroethylene, copolymer tetrafluoroethylene andhexafluoropropylene; polyethylene vinylacetate (EVA), polyimide;polysulfone; polycarbonate; polyethylene; polypropylene;polyvinylchloride-acrylic copolymer;polycarbonate-acrylonitrile-butadiene-styrene; polystyrene; cellulosicpolymers; and the like. Further exemplary polymers are described in TheHandbook of Common Polymers, Scott and Roff, CRC Press, Cleveland RubberCo., Cleveland, Ohio.

Metallic materials suitable for use in the reservoir of the drug releasedevice include stainless steel, titanium, platinum, tantalum, gold andtheir alloys; gold-plated ferrous alloys; platinum-plated titanium,stainless steel, tantalum, gold and their alloys as well as otherferrous alloys; cobalt-chromium alloys; and titanium nitride-coatedstainless steel, titanium, platinum, tantalum, gold, and their alloys.

Exemplary materials for use in polymeric matrices include, but are notnecessarily limited to, biocompatible polymers, including biostablepolymers and biodegradable polymers. Exemplary biostable polymersinclude, but are not necessarily limited to silicone, polyurethane,polyether urethane, polyether urethane urea, polyamide, polyacetal,polyester, poly ethylene-chlorotrifluoroethylene,polytetrafluoroethylene (PTFE or “Teflon™”), styrene butadiene rubber,polyethylene, polypropylene, polyphenylene oxide-polystyrene,poly-a-chloro-p-xylene, polymethylpentene, polysulfone and other relatedbiostable polymers. Exemplary biodegradable polymers include, but arenot necessarily limited to, polyanhydrides, cyclodestrans,polylactic-glycolic acid, polyorthoesters, n-vinyl alcohol, polyethyleneoxide/polyethylene terephthalate, polyglycolic acid, polylactic acid andother related bioabsorbable polymers.

Where the drug formulation is stored in a reservoir comprising metal ora metal alloy, particularly titanium or a titanium alloy having greaterthan 60%, often greater than 85% titanium is preferred for the mostsize-critical applications, for high payload capability and for longduration applications and for those applications where the formulationis sensitive to body chemistry at the implantation site or where thebody is sensitive to the formulation. Most preferably, the drug deliverydevices are designed for storage with drug at room temperature orhigher.

Drug release devices suitable for use in the invention may be based onany of a variety of modes of operation. For example, the drug releasedevice can be based upon a diffusive system, a system that employspositive pressure, etc. For example, the drug release device may bebased upon an electrodiffusion system, an electrolytic pump, aneffervescent pump, a piezoelectric pump, a hydrolytic system, etc.

Drug release devices based upon a mechanical or electromechanicalinfusion pump, can also be suitable for use with the present invention.Examples of such devices include those described in, for example, U.S.Pat. Nos. 4,692,147; 4,360,019; 4,487,603; 4,360,019; 4,725,852, WO97/27840 and U.S. Pat. Nos. 5,985,305 and 5,728,396; and the like.

In one embodiment, the drug release device is a controlled drug releasedevice in the form of an osmotically-driven device. Exemplaryosmotically-driven devices suitable for use in the invention include,but are not necessarily limited to, those described in U.S. Pat. Nos.3,760,984; 3,845,770; 3,916,899; 3,923,426; 3,987,790; 3,995,631;3,916,899; 4,016,880; 4,036,228; 4,111,202; 4,111,203; 4,203,440;4,203,442; 4,210,139; 4,327,725; 4,627,850; 4,865,845; 5,057,318;5,059,423; 5,112,614; 5,137,727; 5,234,692; 5,234,693; 5,728,396; andthe like.

In some embodiments it may be desirable to provide a drug deliverycatheter with the drug delivery device, e.g., where the implantationsite and the desired delivery site are not the same or adjacent. Thedrug delivery catheter is generally a substantially hollow elongatemember having a first end (or “proximal” end) associated with the drugrelease device of the drug delivery device, and a second end (or“distal” end) for delivery of the drug-comprising formulation to adesired delivery site. Where a drug delivery catheter is used, a firstend of the drug delivery catheter is associated with or attached to thedrug delivery device so that the lumen of the drug delivery catheter isin communication with the drug reservoir in the drug delivery device, sothat a formulation contained in a drug reservoir can move into the drugdelivery catheter, and out a delivery outlet of the catheter which ispositioned at the desired delivery site.

The body of the catheter defines a lumen, which lumen is to have adiameter compatible with providing leak-proof delivery of drugformulation from the drug delivery device. The body of the catheter canbe of any of a variety of dimensions and geometries (e.g., curved,substantially straight, tapered, etc.) that can be selected according totheir suitability for the intended site for drug delivery. The distalend of the drug delivery catheter can provide a distinct opening fordelivery of drug, or as a series of openings.

The drug delivery catheter may be produced from any of a variety ofsuitable materials, and may be manufactured from the same or differentmaterial as the reservoir of the drug release device. Impermeablematerials suitable for use in production of the controlled drug releasedevice as described above are generally suitable for use in theproduction of the drug delivery catheter. Exemplary materials from whichthe drug delivery catheter can be manufactured include, but are notnecessarily limited to, polymers; metals; glasses; polyolefins (highdensity polyethylene (HDPE), low density polyethylene (LDPE), linear lowdensity polyethylene (LLDPE), polypropylene (PP), and the like); nylons;polyethylene terephtholate; silicones; urethanes; liquid crystalpolymers; PEBAX®; HYTREL®; TEFLON®; perfluoroethylene (PFE)perfluoruoalkoxy resins (PFA); poly(methyl methacrylate) (PMMA);multilaminates of polymer, metals, and/or glass; nitinol; and the like.

The drug delivery catheter can comprise additional materials or agents(e.g., coatings on the external or internal catheter body surface(s)) tofacilitate placement of the drug delivery catheter and/or to provideother desirable characteristics to the catheter. For example, the drugdelivery catheter inner and/or outer walls can be coated with silver orotherwise coated or treated with antimicrobial agents, thus furtherreducing the risk of infection at the site of implantation and drugdelivery.

Treatment of a Subject for Hypertension with an Implantable DrugDelivery Device

In certain embodiments, a subject is treated for hypertension using animplantable drug delivery device. In these embodiments, the drugdelivery device delivers a prohypertensive, e.g., sympathetic biasenhancing, agent in a manner effective to cause the subject to mount acompensatory response, e.g., in the form of a long-term decrease insympathetic bias.

A variety of prohypertensive agents are known and may be employed.Representative prohypertensive agents include, but are not limited to:Aldosterone, Alpha agonists, angiotensin agonists, calcium channelagonists, corticotropin agonists, anti-diuretics, dopamine agonists,epinephrine and norepinephrine agonists, glucorticoid agonists,mineralcorticoid agonists, oxycontin agonists, renin agonists, andvasopressin agonists. Representative agents for each of these classesare provided in Appendix B of U.S. Provisional Patent Application No.60/650,192, the disclosure of which is herein incorporated by reference.In addition, representative agents for each of these classes are foundin Pharmaprojects, published by PJB Publishing, Version 5.0, London UK(November, 2004).

In certain embodiments, the agent employed has sympathetic biasenhancing activity. By sympathetic bias enhancing activity, it is meantthat the agent, when administered to a subject, produces an increase inthe sympathetic bias of the subject. Specifically, the agent causes theratio of sympathetic activity to parasympathetic activity in the subjectto be increased. Methods of determining sympathetic activity andparasympathetic activity in a subject are known in the art. A givenagent is considered to be a sympathetic bias enhancing agent if, uponadministration to a subject, it causes an increase in the ratio ofsympathetic to parasympathetic activities of at least about 2-fold, suchas at least about 5-fold, including at least about 10-fold.

As indicated above, the agent is administered to a subject in a mannereffective to cause the subject to mount a compensatory responseeffective to treat the hypertension. In representative embodiments, thesympathetic bias enhancing agent is administered to the subject in amanner such that a short term increase in sympathetic bias in thesubject is achieved that results in the production of along termdecrease in sympathetic bias in the subject. The increase and decreasein sympathetic bias referred to above is in reference to the sympatheticbias prior to administration of the agent. In general the magnitude ofthe increase and decrease is at least about 2-fold, such as at leastabout 5-fold, including at least about 10-fold. In the most generalsense, the phrases “short term” and “long term” as used herein arerelative to each other, where the duration of sympathetic bias increaseis considered short term if it is shorter than the resultant duration ofsympathetic bias decrease, e.g., by at least 1 day, such as by at least1 week, including by at least 1 month. In representative embodiments,short term increase in sympathetic bias has a duration of at least about1 second, such as at least about 1 minute, including at least about 30seconds, but lasts no more than about 2 hours, including no more thanabout 90 minutes, such as no more than about 60 minutes. Inrepresentative embodiments, the long term decrease in sympathetic biashas a duration of at least about 1 second, such as at least about 12hours, including at least about 1 hour, where the duration may be aslong as 5 years or longer, including as long as 1 month or longer.

In certain embodiments, the short term increase in sympathetic bias isachieved by administering the agent in a manner such that the agent isactive for only a short duration, where by short duration is meant thatthe applied stimulus lasts for less than about 1 week, e.g., less thanabout 3 days, e.g., less than about 1 day, e.g., less than about 12hours, where the duration of the applied stimulus may be even shorter.

Following delivery of the agent from the implanted device, the subjectis permitted to mount a compensatory response, e.g., in the form of along term decrease in sympathetic bias. In this step of the subjectmethods, no additional sympathetic bias enhancing agent is administeredto the subject. The duration of this period, which may be a periodbetween agent administration (depending on the particular embodiment),may vary. However, in representative embodiments, this period, which maybe referred to as a “holiday” period, is at least about 1 day, such asat least about 2 days, including at least about 5 days, at least about10 days, at least about 15 days, or longer.

In certain embodiments, the methods include close monitoring orsupervision of the subject during and/or after administration of theagent. This monitoring may be completely automated, or at least in partperformed manually, e.g., by a health care professional. For example, ahealth care professional can closely watch the subject followingadministration of the agent as well as during the holiday periodfollowing agent administration, and based on this monitoring determinewhen a next dosage of agent should be delivered. Monitoring also assuresthat the sympathetic bias enhancement is not so severe as to beultimately damaging to the subject at an unacceptable level. Certainaspects of the monitoring may be automated. For example, followingadministration, the subject may enter one or more physiologicalparameters into an automated system, which uses the input parameters toautomatically determine whether the subject is staying within apredetermined set of physiological parameters, or whether interventionis necessary. In certain embodiments, the automated monitoring systemmay also be integrated with an agent delivery device, such that thesystem, based on monitored parameters, determines when next toadminister a dose of agent, the dosage of the next dose, etc. As such,the method may be characterized as administering a first dose to thesubject and monitoring the subject for a response thereto. Followingthis first step, the method further includes administering at least asecond dose to the subject, wherein the second dose is determined basedon the monitored response to the first dose.

In certain embodiments, doses of agent are administered to the subjectin an “irregularly irregular” manner. As such, dosages and timingthereof, as well as duration of holiday periods between such events,varies randomly over the entire course of a treatment, or at least aportion thereof. In addition, the variation does not follow any pattern,but instead is random.

Treatment of a Subject for Hypertension with an ImplantableElectrostimulatory Device

In certain embodiments, a subject is treated for hypertension using animplantable electrostimulatory device. In these embodiments, theelectrostimulatory device delivers an electrical stimulus to a targetsite(s) of a subject in a manner effective to cause the subject to mounta compensatory response, e.g., in the form of a long-term decrease insympathetic bias.

In certain embodiments, the implantable device is operated in a mannerthat produces a sympathetic bias in a subject, as described above. Incertain embodiments, the short term increase in sympathetic bias isachieved by applying the stimulus in a manner such that the agent isactive for only a short duration, where by short duration is meant thatthe applied stimulus lasts for less than about 1 week, e.g., less thanabout 3 days, e.g., less than about 1 day, e.g., less than about 12hours, where the duration of the applied stimulus may be even shorter.

Following delivery of the agent from the implanted device, the subjectis permitted to mount a compensatory response, e.g., in the form of along term decrease in sympathetic bias. In this step of the subjectmethods, no additional stimulus is applied to the subject. The durationof this period, which may be a period between stimulus application(depending on the particular embodiment), may vary. However, inrepresentative embodiments, this period, which may be referred to as a“holiday” period, is at least about 1 day, such as at least about 2days, including at least about 5 days, at least about 10 days, at leastabout 15 days, or longer.

In certain embodiments, the methods include close monitoring orsupervision of the subject during and/or after administration of theagent. This monitoring may be completely automated, or at least in partperformed manually, e.g., by a health care professional. For example, ahealth care professional can closely watch the subject followingstimulus application as well as during the holiday period followingagent administration, and based on this monitoring determine when a nextstimulus should be applied. Monitoring also assures that the sympatheticbias enhancement is not so severe as to be ultimately damaging to thesubject at an unacceptable level. Certain aspects of the monitoring maybe automated. For example, following stimulus application, the subjectmay enter one or more physiological parameters into an automated system,which uses the input parameters to automatically determine whether thesubject is staying within a predetermined set of physiologicalparameters, or whether intervention is necessary. In certainembodiments, the automated monitoring system may also be integrated withthe stimulatory device, such that the system, based on monitoredparameters, determines when next to administer a dose of agent, thedosage of the next dose, etc. As such, the method may be characterizedas administering a first stimulus to the subject and monitoring thesubject for a response thereto. Following this first step, the methodfurther includes administering at least a second stimulus to thesubject, wherein the second stimulus is determined based on themonitored response to the first stimulus.

In certain embodiments, doses of agent are administered to the subjectin an “irregularly irregular” manner. As such, dosages and timingthereof, as well as duration of holiday periods between such events,varies randomly over the entire course of a treatment, or at least aportion thereof. In addition, the variation does not follow any pattern,but instead is random.

EXPERIMENTAL

The following examples are put forth so as to provide those of ordinaryskill in the art with a complete disclosure and description of how tomake and use the present invention, and are not intended to limit thescope of what the inventors regard as their invention. Efforts have beenmade to ensure accuracy with respect to numbers used (e.g. amounts,temperature, etc.) but some experimental errors and deviations should beaccounted for. Unless indicated otherwise, parts are parts by weight,molecular weight is weight average molecular weight, temperature is indegrees Centigrade, and pressure is at or near atmospheric.

I. Example of Paradoxical Pulsed Therapy Using Neurostimulation

One example of utilizing pulsed paradoxical therapy for the treatment ofhypertension includes using an implanted neurostimulation device orcombination of devices with pulsed stimulation of autonomic nerves. Thisdevice induces intermittent electrical stimulation of sympathetic nervesto induce short intervals of increased blood pressure ranging fromseconds to hours to increase dynamic range. Alternatively, or inaddition, this device induces intermittent electrical stimulation ofparasympathetic nerves to induce short intervals of decreased bloodpressure ranging from seconds to hours to increase dynamic range. Inaddition, one could use measured feedback to regulate the frequency andduration of pulsed therapies.

A. Dog Studies Example Study 1 Effect of Paradoxical PulsedNeurostimulation Therapy in Hypertensive Dogs

Double-blinded randomized controlled studies are performed in a set ofdogs with experimentally induced hypertension to demonstrate thatintermittent electrical stimulation of sympathetic nerves lowers bloodpressure. Experiments are conducted on mongrel dogs of either sexweighing 14-17 kg. Dogs are prepared for study by being treated forectoparasites and endoparasites in addition to being immunized forparvovirus, canine distemper, hepatitis, parainfluenza, and coronavirus.All experiments are conducted in accordance with the National Institutesof Health Guide for the Care and Use of Laboratory Animals. Dogs are feda low sodium diet supplemented with sodium chloride to achieve a sodiumintake of 40 mmol/d (normal sodium intake). This dietary regimenprovides a constant and known level of dietary sodium intake. Throughoutthe experimental protocol, all dogs are allowed water ad libidum.

For implantation of the neurostimulation devices, dogs are anesthetizedwith sodium thiamylal (30 mg/kg IV) for induction and then halothane(1%). Sympathetic nerves in candidate plexi are isolated and affixed tobipolar stimulating electrodes. Catheters are inserted via the femoralvessels into the aorta for direct arterial pressure measurement. Allcatheter lines are tunneled subcutaneously to the midscapular region ofthe back and exteriorized. A 10-day steady state control period precedesthe experimental period for all subjects to allow for recovery fromsurgical instrumentation.

Throughout the experimental period, dogs in the treatment groupinitially receive pulsed stimulation with pulse duration ranging fromabout 1 to about 10800 seconds at a frequency no less than 1 to about1440 pulses per day. Dogs in the control group receive no stimulationduring the experimental period. Measurement of systolic, diastolic, andmean arterial blood pressures are obtained via pressure transducer on anongoing basis. Measurements continue for a recovery period of 15 daysfollowing completion of pulsed administration.

In accordance with changes in the measured parameters, the schedule ofadministration of pulses is actively modified in the following manner:for any increase in systolic pressure of greater than 1-10 mm Hg ordiastolic pressure of greater than 1-10 mm Hg, the frequency ofadministration of pulses is decreased by 1-1440 per day and/or theduration of each pulse is decreased by 1-10800 seconds. For any decreasein systolic pressure of greater than 1-10 mm Hg or diastolic pressure ofgreater than 1-10 mm Hg, the frequency of administration of pulses isincreased by 1-1440 per day and/or the duration of each pulse would beincreased by 1-10800 seconds.

In order to assess potential effects in other systems where sympatheticactivity typically exerts influence, arterial blood samples andpulmonary function tests are obtained on a weekly schedule where thefollowing parameters may be assessed:

Test Reference value Claimed Range pulmonary gas Alveolar oxygen 650-713mmHg 600-713 mmHg serum blood gas pH 7.35-7.45 7.1 to 7.7  arterial pO280-100 mmHg 50-110 arterial pcO2 35-45 mmHg 10 to 80  arterial bicarb25-35 meq/L 10 to 40  alveolar/oxygen ratio    0.8  1 to 0.6 aa gradient10-15 mmHg  5 to 120 venous oxygen sat  60%  30-80% cardoipulmonarycardiac output 3.5 to 5.5 L/min 1 to 6  cardiac index 2.8-3.2 L/min/m20.5 to 6   right atrial pressure 1-7 mmHg 1 to 30 right ventricularsystolic pressure 15-25 mmHg 5 to 50 right ventricular diastolicpressure 0-8 mm Hg 1 to 50 pulmonary arterial systolic pressure 15-25mmHg 5 to 50 pulmonary arterial diastolic pressure 8-15 mmHg 1 to 30mean pulmonary arterial pressure 10-20 mmHg 5 to 50 pulmonary capillarywedge pressure 6-12 mmHg 1 to 20 pulmonary tidal volume 8-15 ml/Kg 2-20or 20-80% function test total lung capacity 5-7 liters 3 to 10 or20-120% residual volume 1.5 to 2.5 liters 0.5 5 or 20-120% forcedexpiratory volume in 1 second 3.5-4 liters 0.5 to 6 or 20-120%functional vital capacity 4-6 liters 0.5 to 6 or 20-120% FEV1/FVCratio >75%   20-120% forced expiratory flow   75-125%   50 to 150% peakexpiratory flow rate   80-100%   60-120% forced expiratory time <5seconds 0-20 seconds corrected diffusion capacity   75-80%   60-140%corrected QT interval <440  <600 sleep study sleep latency >10 min 0-1hour total sleep time >5.5 hours 0-12 hours percent rem >15% of TST0-40% total sleep time percent stage 3-4 non rem >25% of TST 0-50% totalsleep time respiratory arousal <5/hour total sleep 0-40/hour total sleepindex time time periodic leg <1/hour total sleep 0-40/hour total sleepmovements time time <1/hour total sleep 0-20/hour total sleep apneaindex time time <3/hour total sleep 0-40/hour total sleep hypopnea indextime time nadir oxygen saturatin >92%   40-100% mean oxygensaturation >95%   40-100% <5 defined 0-40 defined as >4% for 5 as >4%for 5 seconds/hour seconds/hour of desaturation index of total sleeptime total sleep time highest carbon dioxide 52 mm Hg 10-80 mmHg carbondioxide >45 <20% of total sleep 0-60% of total sleep mmHg time timeSerum Markers Catecholamine levels Acetycholine levels 650-1500 IU/L300-2000 IU/L Aldosterone levels 17-70 nmol/day 5-150 nmol/L/day Reninlevels 7-76 uU/mL 3-200 uU/ml Vasopressin levels 2-8 pg/mL 1-20 pg/mlangiotensin converting enzyme 25-100 IU/L 5-200 U/L levels interleukin1-3 and modulate 5-13 and 18 Interleukin 4 decrease interferon alpha andmodulate beta interferon gamma increase tumor necrosis modulate factoralpha transforming growth modulate factor hemoglobin A1C   4-8%   2-12%Fasting glucose 3.5-6.0 mmol/L 1-10 mmol/L high density 45-60 10 to 90 lipoprotein low density  95-130 60-200 lipoprotein triglyceride <2mmol/L 4 to 4 mmol/L beta natriuretic 20-40 pg/mL 0-100 pg/mL peptidealpha natriuretic 20-40 pg/mL 0-50 pg/mL peptide erythrocyte 0-35mm/Hour 1-200 mm/Hour sedimentation rate c reactive peptide <10 mg/L1-80 mg/L transferrin 1.75 to 3.13 g/L 0.5 to 6 g/L Hemloglobin 135-160gm/L 25 to 300 gm/L hematocrit   37-54%  25-60% ferritin 20-240 ug/L 5to 600 ug/L iron 10-40 umol/L 5 to 100 umol/L cholinesterase 650-1500IU/L 200-2500 IU/L Urine adrenaline 0-80 nmol/day 0-200 nmol/day Urinenoradrenaline 0-780 nmol/day 0-1600 nmol/day Urine dopamine 0-3500nmol/day 0-7000 nmol/day adrenocorticotrophic <19 pmol/L 0 to 40 pmol/Lhormone antidiuretic hormone 2-8 pg/mL 1-20 pg/mL thrombin clotting10-20 secs 5-30 secs time total serum 110-120 100-300  cholesteroleAdditional body mass index 20-30 <40 systolic blood <125  90-180pressure diastolic blood pressure <75 30-100 pulse pressure <20 20-40 heart rate  60-100 30-200 heart rate variability increase respiratorysinus arrhythmia increase

All dogs in the treatment group are observed to initially have either nochanges or statistically negligible increases in systolic, diastolic,and mean arterial pressures while the compensatory response toadministration begins to take hold. At some point during theexperimental period these dogs are observed to begin to manifestreductions in systolic, diastolic, and mean arterial pressures. Thefrequency and duration of pulses is gradually increased so as toincrease the magnitude of the reduction for the duration of theexperimental period. These reductions are maintained upon cessation ofthe treatment for the duration of the recovery period. Dogs in thecontrol group maintain the same values in these parameters throughoutboth the control period and the experimental period. No adverse effectsof treatment are found in any of these subjects.

Example Study 2

Effect of Paradoxical Pulsed Neurostimulation Therapy in NormotensiveDogs

In double-blinded randomized controlled studies performed in similarfashion to that described in Example 1, the effect of pulsed stimulationof sympathetic nerves on the blood pressure in normotensive dogs isdetermined. The control period in this case is 10 days and theexperimental period 30 days. Again, dogs in the treatment group receivepulsed stimulation of selected sympathetic nerves using implantedbipolar electrodes with pulse duration of from about 1 to about 10800seconds at a frequency no less than about 1 to about 1440 per day. Theschedule of pulse administration is adjusted during the course of theexperimental period by the protocol as previously noted. Controlsubjects have similar devices implanted but do not receive any pulsedstimulation for the duration of the treatment period.

As with the hypertensive dogs, the pulsed electrical stimulation ofsympathetic nerves in normotensive dogs results in significantreductions in mean arterial pressures maintained upon cessation oftreatment. Dogs in the control group maintain the same mean arterialpressure throughout both the control period and the experimental period.Findings of reduction in normotensive dogs show that paradoxical pulsedtherapy readily finds prophylactic use in preventing the onset ofhypertension in individuals identified as predisposed to the condition.

B. Human Studies Example Study 1 Effect of Paradoxical PulsedNeurostimulation Therapy in Hypertensive Patients

Double-blinded randomized controlled studies are performed in a set ofpatients with essential hypertension to demonstrate that intermittentelectrical stimulation of sympathetic nerves lowers blood pressure. Inall patients, hypertension is confirmed on at least three occasions inan outpatient setting after the patient has been sitting for at least 10minutes. Blood pressure ranges recorded indicate elevation of bothsystolic and diastolic components of the blood pressure. No patientshave clinical signs or symptoms of pheochromocytoma or renal arterystenosis, and no patients have clinical or laboratory evidence ofimpaired cardiac, renal, pulmonary, or hepatic function. Urinalysis andserum concentrations of creatinine, sodium, and potassium are confirmedto be within normal limits for patients.

All medications are stopped for each individual for at least four weeksbefore the beginning of the study. All patients remain hospitalizedthroughout the study, where physical activity consists of only dailywalks. Throughout the study, each patient ingests a constant amount of anutritionally adequate whole-foods diet intrinsically low in sodiumchloride (approximately 10 mmoles NaCl/70 kg body weight/day). A sodiumchloride supplement is added in an amount sufficient to increase totalsodium intake to 140 meq/day/70 kg. The diet provides approximately 55mmoles of potassium, 375 mg of calcium, and 820 mg of phosphorus per 70kg/day.

In each patient, the total number of calories provided is determinedfrom the estimated amount of energy required to keep body weightconstant. The diet contains, as a percentage of total calories, 35% fat,56% carbohydrate, and 9% protein. The specific ingredients of each mealare kept constant throughout the study. Fluid intake would be fixed at3150 ml/70 kg/day.

A 10-day steady state control period precedes the experimental periodfor all subjects. Throughout the experimental period, all patients inthe treatment group initially receive pulsed stimulation of selectedsympathetic nerves using an implanted neurostimulation device with pulseduration of from about 1 to about 10800 seconds at a frequency no lessthan about 1 to about 1440 per day. Control subjects would have similardevices implanted but would not receive pulsed stimulation for theduration of the treatment period.

Blood pressure is measured in the nondominant arm at 8 am, noon, 4 pm, 8pm, and 10 pm of each day, with an automated oscillometric device(Dinamap) in order to avoid observer bias. At each measurement session,after the patient has been supine for 10 minutes, five measurements ofsystolic and diastolic pressure and heart rate are obtained and theaverage of the last four measurements are calculated. The measurementsare repeated with the patient in the upright position at each session.The measurements are averaged to yield values for daily systolic anddiastolic blood pressures. Mean arterial pressure is calculated as(systolic pressure−diastolic pressure)/3+diastolic pressure.Measurements continue for a recovery period of 15 days followingcompletion of pulsed administration.

In accordance with changes in the measured parameters, the schedule ofadministration of pulses would be actively modified in the followingmanner: for any increase in systolic pressure of greater than 1-10 mm Hgor diastolic pressure of greater than 1-10 mm Hg, the frequency ofadministration of pulses is decreased by 1-1440 per day and/or theduration of each pulse is decreased by 1-10800 seconds. For any decreasein systolic pressure of greater than 1-10 mm Hg or diastolic pressure ofgreater than 1-10 mm Hg, the frequency of administration of pulses isincreased by 1-1440 per day and/or the duration of each pulse isincreased by 1-10800 seconds.

In order to assess potential effects in other systems where sympatheticactivity typically exerts influence, the following parameters may beassessed with the accompanying range of values observed as indicated:

Test Reference value Claimed Range pulmonary gas Alveolar oxygen 650-713mmHg 600-713 mmHg serum blood gas pH 7.35-7.45 7.1 to 7.7  arterial pO280-100 mmHg 50-110 arterial pcO2 35-45 mmHg 10 to 80  arterial bicarb25-35 meq/L 10 to 40  alveolar/oxygen ratio    0.8  1 to 0.6 aa gradient10-15 mmHg  5 to 120 venous oxygen sat 60%  30-80% cardoipulmonarycardiac output 3.5 to 5.5 L/min 1 to 6  cardiac index 2.8-3.2 L/min/m20.5 to 6   right atrial pressure 1-7 mmHg 1 to 30 right ventricularsystolic pressure 15-25 mmHg 5 to 50 right ventricular diastolicpressure 0-8 mm Hg 1 to 50 pulmonary arterial systolic pressure 15-25mmHg 5 to 50 pulmonary arterial diastolic pressure 8-15 mmHg 1 to 30mean pulmonary arterial pressure 10-20 mmHg 5 to 50 pulmonary capillarywedge pressure 6-12 mmHg 1 to 20 pulmonary tidal volume 8-15 ml/Kg 2-20or 20-80% function test total lung capacity 5-7 liters 3 to 10 or20-120% residual volume 1.5 to 2.5 liters 0.5 5 or 20-120% forcedexpiratory volume in 1 second 3.5-4 liters 0.5 to 6 or 20-120%functional vital capacity 4-6 liters 0.5 to 6 or 20-120% FEV1/FVCratio >75%   20-120% forced expiratory flow   75-125%   50 to 150% peakexpiratory flow rate   80-100%   60-120% forced expiratory time <5seconds 0-20 seconds corrected diffusion   75-80%   60-140% capacitycorrected QT <440  <600  interval sleep study sleep latency >10 min 0-1hour total sleep time >5.5 hours 0-12 hours percent rem >15% of TST0-40% total sleep time percent stage 3-4 >25% of TST 0-50% total sleepnon rem time respiratory arousal <5/hour total sleep 0-40/hour totalsleep index time time periodic leg <1/hour total sleep 0-40/hour totalsleep movements time time apnea index <1/hour total sleep 0-20/hourtotal sleep time time hypopnea index <3/hour total sleep 0-40/hour totalsleep time time nadir oxygen >92%   40-100% saturatin mean oxygen >95%  40-100% saturation desaturation index <5 defined 0-40 defined as >4%for 5 as >4% for 5 seconds/hour of seconds/hour of total sleep timetotal sleep time highest carbon 52 mm Hg 10-80 mmHg dioxide carbondioxide >45 <20% of total sleep 0-60% of total sleep mmHg time timeSerum Markers Catecholamine levels Acetycholine levels 650-1500 IU/L300-2000 IU/L Aldosterone levels 17-70 nmol/day 5-150 nmol/L/day Reninlevels 7-76 uU/mL 3-200 uU/ml Vasopressin levels 2-8 pg/mL 1-20 pg/mlangiotensin converting enzyme 25-100 IU/L 5-200 U/L levels interleukin1-3 and modulate 5-13 and 18 Interleukin 4 decrease interferon alpha andmodulate beta interferon gamma increase tumor necrosis modulate factoralpha transforming growth modulate factor hemoglobin A1C   4-8%   2-12%Fasting glucose 3.5-6.0 mmol/L 1-10 mmol/L high density 45-60 10 to 90 lipoprotein low density  95-130 60-200 lipoprotein triglyceride <2mmol/L 4 to 4 mmol/L beta natriuretic 20-40 pg/mL 0-100 pg/mL peptidealpha natriuretic 20-40 pg/mL 0-50 pg/mL peptide erythrocyte 0-35mm/Hour 1-200 mm/Hour sedimentation rate c reactive peptide <10 mg/L1-80 mg/L transferrin 1.75 to 3.13 g/L 0.5 to 6 g/L Hemloglobin 135-160gm/L 25 to 300 gm/L hematocrit   37-54%  25-60% ferritin 20-240 ug/L 5to 600 ug/L iron 10-40 umol/L 5 to 100 umol/L cholinesterase 650-1500IU/L 200-2500 IU/L Urine adrenaline 0-80 nmol/day 0-200 nmol/day Urinenoradrenaline 0-780 nmol/day 0-1600 nmol/day Urine dopamine 0-3500nmol/day 0-7000 nmol/day adrenocorticotrophic <19 pmol/L 0 to 40 pmol/Lhormone antidiuretic hormone 2-8 pg/mL 1-20 pg/mL thrombin clotting10-20 secs 5-30 secs time total serum cholesterole 110-120 100-300 Additional body mass index 20-30 <40 systolic blood <125  90-180pressure diastolic blood <75 30-100 pressure pulse pressure <20 20-40 heart rate  60-100 30-200 heart rate variability increase respiratorysinus increase arrhythmia

All patients in the treatment group initially have either no changes orstatistically negligible increases in systolic, diastolic, and meanarterial pressures while the compensatory response to administrationbegins to take hold. At some point during the experimental period thesepatients begin to manifest reductions in systolic, diastolic, and meanarterial pressures. The frequency and duration of pulses is graduallyincreased so as to increase the magnitude of the reduction for theduration of the experimental period. These reductions are maintainedupon cessation of the treatment for the duration of the recovery period.Patients in the control group maintain the same values in theseparameters throughout both the control period and the experimentalperiod. No adverse effects of treatment are found in any of thesesubjects.

Example Study 2 Effect of Paradoxical Pulsed Neurostimulation Therapy inNormotensive Patients

In double blinded randomized controlled studies performed in similarfashion to that described in Example 1, the effect of intermittentstimulation of sympathetic nerves on the blood pressure in normotensiveindividuals is determined. The control period in this case is again 10days and the experimental period 30 days. Again, patients in thetreatment group receive pulsed stimulation of selected sympatheticnerves using an implanted neurostimulation device with pulse duration1-10800 seconds at a frequency no less than 1-1440 per day. The scheduleof pulse administration is adjusted during the course of theexperimental period by the protocol as previously noted. Controlsubjects have similar devices implanted but do not receive any pulsedstimulation for the duration of the treatment period. The subjects arefed a diet having an intrinsic low-sodium chloride content (less than 10meq sodium and chloride/day/70 kg body weight) and a normal potassiumcontent (52 meq/day/70 kg body weight). A sodium chloride supplement isadded sufficient to increase total sodium intake to 140 meq/70 kg/day.

As with the hypertensive individuals, pulsed electrical stimulation ofsympathetic nerves results in significant reductions in mean arterialpressures maintained upon cessation of treatment. Patients in thecontrol group maintain the same mean arterial pressure throughout boththe control period and the experimental period. Findings of reduction innormotensive individuals means that paradoxical pulsed therapy findsprophylactic use in preventing the onset of hypertension in individualsidentified as predisposed to the condition.

C. Materials and Methods 1. Method for Stimulation of SympatheticActivity

Splanchnic nerves are ideal candidates for sympathetic nerve stimulationgiven their size and location. An electrical device for stimulation isadapted for application to relevant nerve bundles. The electrodes ofthis device consist of bipolar electrodes that generate actionpotentials by cathodic stimulation and produce a complete anodal blockon one side of the cathode to make the electrode-generated actionpotentials unidirectional. Each bipolar electrode contains an insulatingbase with cathode and anode on one face and control circuitry on theopposite face. This apparatus communicates with a master control uniteither attached to the bipolar electrodes directly via an asynchronousserial bus or via wireless communication link. 1-5 Hz has been describedas the frequency that best describes the conduction velocity, latency,and refractory period of sympathetic nerves, and range of amplitude ofcurrent delivered can vary between 0.1 and 20 A.

2. Method for Inhibition of Parasympathetic Activity

Alternatively, the vagus nerve offers a candidate for increasingrelative sympathetic activity via inhibition of parasympatheticactivity. An electrical device for stimulation is adapted forapplication to relevant nerve bundles. The electrodes for this deviceconsist of tripolar electrodes that produce a complete block of vagalactivity by generating action potentials via cathodic stimulation andimposing complete anodal blocks in either direction. Each tripolarelectrode contains an insulating base with cathodes and anodes on oneface and control circuitry on the opposite face. This apparatuscommunicates with a master control unity either attached to the tripolarelectrodes directly via an asynchronous serial bus or via wirelesscommunication link. 10-150 Hz has been described as the frequency thatbest describes the conduction velocity, latency, and refractory periodof parasympathetic nerves, and range of amplitude of current deliveredcan vary between 0.1 and 20 A.

II. Example of Paradoxical Pulsed Therapy Using PharmacologicStimulation

An example of utilizing pulsed paradoxical therapy for the treatment ofhypertension includes using a short-acting sympathomimetic agent toproduce short intervals of increased blood pressure ranging from secondsto hours to increase dynamic range. Alternatively, or in addition, onecould deploy a short-acting parasympathomimetic agent to induce toinduce short intervals of decreased blood pressure ranging from secondsto hours to increase dynamic range. In addition, one could use measuredfeedback to regulate the frequency and duration of pulsed therapies.

A. Dog Studies Example Study 1

Effect of Paradoxical Pulsed Pharmacologic Therapy in Hypertensive Dogs

Double-blinded randomized controlled studies are performed in a set ofdogs with experimentally induced hypertension (mechanism of induction tobe determined) to demonstrate that intermittent stimulation withsympathomimetic pharmacologic agents lowers blood pressure. Experimentsare conducted on mongrel dogs of either sex weighing 14-17 kg. Dogs areprepared for study by being treated for ectoparasites and endoparasitesin addition to being immunized for parvovirus, canine distemper,hepatitis, parainfluenza, and coronavirus. All experiments are conductedin accordance with the National Institutes of Health Guide for the Careand Use of Laboratory Animals. Dogs are fed a low sodium dietsupplemented with sodium chloride to achieve a sodium intake of 40mmol/d (normal sodium intake). This dietary regimen provides a constantand known level of dietary sodium intake. Throughout the experimentalprotocol, all dogs are allowed water ad libidum.

For implantation of catheters for controlled administration of theagents, dogs are anesthetized with sodium thiamylal (30 mg/kg IV) forinduction and then halothane (1%). Catheters are inserted via thefemoral vessels into the aorta for direct arterial pressure measurementand drug administration. All catheter lines are tunneled subcutaneouslyto the midscapular region of the back and exteriorized. A 10-day steadystate control period precedes the experimental period for all subjectsto allow for recovery from surgical instrumentation.

Throughout the experimental period, dogs in the treatment groupinitially receive pulsed stimulation via pulsatile administration of asympathomimetic agent at a frequency no less than 1 to about 1440 pulsesper day. Dogs in the control group receive a placebo at the samefrequency during the experimental period. Measurement of systolic,diastolic, and mean arterial blood pressures are obtained via pressuretransducer on an ongoing basis. Measurements continue for a recoveryperiod of 15 days following completion of pulsed administration.

In accordance with changes in the measured parameters, the schedule ofadministration of pulses is actively modified in the following manner:for any increase in systolic pressure of greater than 1-10 mm Hg ordiastolic pressure of greater than 1-10 mm Hg, the frequency ofadministration of the agent is decreased by 1-1440 per day and/or thedosing of the agent is decreased by 1-99%. For any decrease in systolicpressure of greater than 1-10 mm Hg or diastolic pressure of greaterthan 1-10 mm Hg, the frequency of administration of the agent isincreased by 1-1440 per day and/or the dosing of the agent is increasedby 1-99%.

In order to assess potential effects in other systems where sympatheticactivity typically exerts influence, arterial blood samples andpulmonary function tests are obtained on a weekly schedule where thefollowing parameters may be assessed:

Test pulmonary gas Alveolar oxygen serum blood gas pH arterial pO2arterial pcO2 arterial bicarb alveolar/oxygen ratio aa gradient venousoxygen sat cardoipulmonary cardiac output cardiac index right atrialpressure right ventricular systolic pressure right ventricular diastolicpressure pulmonary arterial systolic pressure pulmonary arterialdiastolic pressure mean pulmonary arterial pressure pulmonary capillarywedge pressure pulmonary tidal volume function test total lung capacityresidual volume forced expiratory volume in 1 second functional vitalcapacity FEV1/FVC ratio forced expiratory flow peak expiratory flow rateforced expiratory time corrected diffusion capacity corrected QTinterval sleep study sleep latency total sleep time percent rem percentstage 3-4 non rem respiratory arousal index periodic leg movements apneaindex hypopnea index nadir oxygen saturatin mean oxygen saturationdesaturation index highest carbon dioxide carbon dioxide >45 mmHg SerumMarkers Catecholamine levels Acetycholine levels Aldosterone levelsRenin levels Vasopressin levels angiotensin converting enzyme levelsinterleukin 1-3 and 5-13 and 18 Interleukin 4 interferon alpha and betainterferon gamma tumor necrosis factor alpha transforming growth factorhemoglobin A1C Fasting glucose high density lipoprotein low densitylipoprotein triglyceride beta natriuretic peptide alpha natriureticpeptide erythrocyte sedimentation rate c reactive peptide transferrinHemloglobin hematocrit ferritin iron cholinesterase Urine adrenalineUrine noradrenaline Urine dopamine adrenocorticotrophic hormoneantidiuretic hormone thrombin clotting time total serum cholesteroleAdditional body mass index systolic blood pressure diastolic bloodpressure pulse pressure heart rate heart rate variability respiratorysinus arrhythmia

All dogs in the treatment group are observed to initially have either nochanges or statistically negligible increases in systolic, diastolic,and mean arterial pressures while the compensatory response toadministration began to take hold. At some point during the experimentalperiod these dogs are observed to begin to manifest reductions insystolic, diastolic, and mean arterial pressures. The frequency anddosage of administration is gradually adjusted so as to increase themagnitude of the reduction for the duration of the experimental period.These reductions are maintained upon cessation of the treatment for theduration of the recovery period. Dogs in the control group maintain thesame values in these parameters throughout both the control period andthe experimental period. No adverse effects of treatment are found inany of these subjects.

Example Study 2 Effect of Paradoxical Pulsed Pharmacologic Therapy inNormotensive Dogs

In double-blinded randomized controlled studies performed in similarfashion to that described in Example 1, the effect of pulsed stimulationvia pulsatile administration of sympathomimetic agents on the bloodpressure in normotensive dogs is determined. The control period in thiscase is 10 days and the experimental period 30 days. Again, dogs in thetreatment group receive pulsed stimulation via pulsatile administrationof a sympathomimetic agent at a frequency no less than about 1 to about1440 per day. The schedule of pulse administration is adjusted duringthe course of the experimental period by the protocol as previouslynoted. Control subjects have comparable devices for administration butreceive a placebo for the duration of the treatment period.

As with the hypertensive dogs, the pulsatile administration of asympathomimetic agent in normotensive dogs results in significantreductions in mean arterial pressures maintained upon cessation oftreatment. Dogs in the control group maintain the same mean arterialpressure throughout both the control period and the experimental period.Findings of reduction in normotensive dogs show that paradoxical pulsedtherapy readily finds prophylactic use in preventing the onset ofhypertension in individuals identified as predisposed to the condition.

B. Human Studies Example Study 1 Effect of Paradoxical PulsedPharmacologic Therapy in Hypertensive Patients

Double-blinded randomized controlled studies are performed in a set ofpatients with essential hypertension to demonstrate that intermittentelectrical stimulation of sympathetic nerves lowers blood pressure. Inall patients, hypertension is confirmed on at least three occasions inan outpatient setting after the patient has been sitting for at least 10minutes. Blood pressure ranges recorded indicate elevation of bothsystolic and diastolic components of the blood pressure. No patientshave clinical signs or symptoms of pheochromocytoma or renal arterystenosis, and no patients have clinical or laboratory evidence ofimpaired cardiac, renal, pulmonary, or hepatic function. Urinalysis andserum concentrations of creatinine, sodium, and potassium are confirmedto be within normal limits for patients.

All medications are stopped for each individual for at least four weeksbefore the beginning of the study. All patients remain hospitalizedthroughout the study, where physical activity consists of only dailywalks. Throughout the study, each patient ingests a constant amount of anutritionally adequate whole-foods diet intrinsically low in sodiumchloride (approximately 10 mmoles NaCl/70 kg body weight/day). A sodiumchloride supplement is added in an amount sufficient to increase totalsodium intake to 140 meq/day/70 kg. The diet provides approximately 55mmoles of potassium, 375 mg of calcium, and 820 mg of phosphorus per 70kg/day.

In each patient, the total number of calories provided is determinedfrom the estimated amount of energy required to keep body weightconstant. The diet contains, as a percentage of total calories, 35% fat,56% carbohydrate, and 9% protein. The specific ingredients of each mealare kept constant throughout the study. Fluid intake would be fixed at3150 ml/70 kg/day.

A 10-day steady state control period precedes the experimental periodfor all subjects. Throughout the experimental period, all patients inthe treatment group initially receive pulsatile administration of asympathomimetic agent via an implanted intravenous catheter at afrequency no less than about 1 to about 1440 per day. Control subjectswould have similar catheters implanted but would receive only placebofor the duration of the treatment period.

Blood pressure is measured in the nondominant arm at 8 am, noon, 4 pm, 8pm, and 10 pm of each day, with an automated oscillometric device(Dinamap) in order to avoid observer bias. At each measurement session,after the patient has been supine for 10 minutes, five measurements ofsystolic and diastolic pressure and heart rate are obtained and theaverage of the last four measurements are calculated. The measurementsare repeated with the patient in the upright position at each session.The measurements are averaged to yield values for daily systolic anddiastolic blood pressures. Mean arterial pressure is calculated as(systolic pressure−diastolic pressure)/3+diastolic pressure.Measurements continue for a recovery period of 15 days followingcompletion of pulsed administration.

In accordance with changes in the measured parameters, the schedule ofadministration of pulses would be actively modified in the followingmanner: for any increase in systolic pressure of greater than 1-10 mm Hgor diastolic pressure of greater than 1-10 mm Hg, the frequency ofadministration is decreased by 1-1440 per day and/or the dosing of theagent is decreased by 1-99%. For any decrease in systolic pressure ofgreater than 1-10 mm Hg or diastolic pressure of greater than 1-10 mmHg, the frequency of administration is increased by 1-1440 per dayand/or the dosing of the agent is increased by 1-99%.

In order to assess potential effects in other systems where sympatheticactivity typically exerts influence, the following parameters may beassessed with the accompanying range of values observed as indicated:

Test Reference value Claimed Range pulmonary gas Alveolar oxygen 650-713mmHg 600-713 mmHg serum blood gas pH 7.35-7.45 7.1 to 7.7  arterial pO280-100 mmHg 50-110 arterial pcO2 35-45 mmHg 10 to 80  arterial bicarb25-35 meq/L 10 to 40  alveolar/oxygen ratio    0.8  1 to 0.6 aa gradient10-15 mmHg  5 to 120 venous oxygen sat  60%  30-80% cardoipulmonarycardiac output 3.5 to 5.5 L/min 1 to 6  cardiac index 2.8-3.2 L/min/m20.5 to 6   right atrial pressure 1-7 mmHg 1 to 30 right ventricular15-25 mmHg 5 to 50 systolic pressure right ventricular 0-8 mm Hg 1 to 50diastolic pressure pulmonary arterial 15-25 mmHg 5 to 50 systolicpressure pulmonary arterial 8-15 mmHg 1 to 30 diastolic pressure meanpulmonary arterial pressure 10-20 mmHg 5 to 50 pulmonary capillary wedgepressure 6-12 mmHg 1 to 20 pulmonary tidal volume 8-15 ml/Kg 2-20 or20-80% function test total lung capacity 5-7 liters 3 to 10 or 20-120%residual volume 1.5 to 2.5 liters 0.5 5 or 20-120% forced expiratoryvolume in 1 second 3.5-4 liters 0.5 to 6 or 20-120% functional vitalcapacity 4-6 liters 0.5 to 6 or 20-120% FEV1/FVC ratio >75%   20-120%forced expiratory flow   75-125%   50 to 150% peak expiratory flow rate  80-100%   60-120% forced expiratory time <5 seconds 0-20 secondscorrected diffusion capacity   75-80%   60-140% corrected QT interval<440  <600  sleep study sleep latency >10 min 0-1 hour total sleeptime >5.5 hours 0-12 hours 0-40% total sleep percent rem >15% of TSTtime percent stage 3-4 0-50% total sleep non rem >25% of TST time<5/hour total respiratory arousal sleep time 0-40/hour total sleep indextime periodic leg <1/hour total 0-40/hour total sleep movements sleeptime time <1/hour total 0-20/hour total sleep apnea index sleep timetime <3/hour total 0-40/hour total sleep hypopnea index sleep time timenadir oxygen saturatin >92%   40-100% mean oxygen saturation >95%  40-100% <5 defined 0-40 defined as >4% for 5 as >4% for 5 seconds/hourof seconds/hour of desaturation index total sleep time total sleep timehighest carbon dioxide 52 mm Hg 10-80 mmHg carbon dioxide >45 <20% oftotal 0-60% of total sleep mmHg sleep time time Serum MarkersCatecholamine levels Acetycholine levels 650-1500 IU/L 300-2000 IU/LAldosterone levels 17-70 nmol/day 5-150 nmol/L/day Renin levels 7-76uU/mL 3-200 uU/ml Vasopressin levels 2-8 pg/mL 1-20 pg/ml angiotensinconverting enzyme 25-100 IU/L 5-200 U/L levels interleukin 1-3 andmodulate 5-13 and 18 Interleukin 4 decrease interferon alpha andmodulate beta interferon gamma increase tumor necrosis factor modulatealpha transforming growth modulate factor hemoglobin A1C   4-8%   2-12%Fasting glucose 3.5-6.0 mmol/L 1-10 mmol/L high density 45-60 10 to 90 lipoprotein low density  95-130 60-200 lipoprotein triglyceride <2mmol/L 4 to 4 mmol/L beta natriuretic peptide 20-40 pg/mL 0-100 pg/mLalpha natriuretic peptide 20-40 pg/mL 0-50 pg/mL erythrocytesedimentation rate 0-35 mm/Hour 1-200 mm/Hour c reactive peptide <10mg/L 1-80 mg/L transferrin 1.75 to 3.13 g/L 0.5 to 6 g/L Hemloglobin135-160 gm/L 25 to 300 gm/L hematocrit   37-54%  25-60% ferritin 20-240ug/L 5 to 600 ug/L iron 10-40 umol/L 5 to 100 umol/L cholinesterase650-1500 IU/L 200-2500 IU/L Urine adrenaline 0-80 nmol/day 0-200nmol/day Urine noradrenaline 0-780 nmol/day 0-1600 nmol/day Urinedopamine 0-3500 nmol/day 0-7000 nmol/day adrenocorticotrophic hormone<19 pmol/L 0 to 40 pmol/L antidiuretic hormone 2-8 pg/mL 1-20 pg/mLthrombin clotting time 10-20 secs 5-30 secs total serum cholesterole110-120 100-300  Additional body mass index 20-30 <40 systolic blood<125  90-180 pressure diastolic blood <75 30-100 pressure pulse pressure<20 20-40  heart rate  60-100 30-200 heart rate variability increaserespiratory sinus increase arrhythmia

All patients in the treatment group initially have either no changes orstatistically negligible increases in systolic, diastolic, and meanarterial pressures while the compensatory response to administrationbegins to take hold. At some point during the experimental period thesepatients begin to manifest reductions in systolic, diastolic, and meanarterial pressures. The frequency and dosage of administration isgradually adjusted so as to increase the magnitude of the reduction forthe duration of the experimental period. These reductions are maintainedupon cessation of the treatment for the duration of the recovery period.Patients in the control group maintain the same values in theseparameters throughout both the control period and the experimentalperiod. No adverse effects of treatment are found in any of thesesubjects.

Example Study 2 Effect of Paradoxical Pulsed Pharmacologic Therapy inNormotensive Patients

In double blinded randomized controlled studies performed in similarfashion to that described in Example 1, the effect of intermittentstimulation of sympathetic nerves on the blood pressure in normotensiveindividuals is determined. The control period in this case is again 10days and the experimental period 30 days. Again, patients in thetreatment group receive pulsatile administration of a sympathomimeticagent via implanted intravenous catheter at a frequency no less than1-1440 per day. The schedule of pulse administration is adjusted duringthe course of the experimental period by the protocol as previouslynoted. Control subjects have similar catheters implanted but receiveonly placebo for the duration of the treatment period. The subjects arefed a diet having an intrinsic low-sodium chloride content (less than 10meq sodium and chloride/day/70 kg body weight) and a normal potassiumcontent (52 meq/day/70 kg body weight). A sodium chloride supplement isadded sufficient to increase total sodium intake to 140 meq/70 kg/day.

As with the hypertensive individuals, pulsatile administration of asympathomimetic agent results in significant reductions in mean arterialpressures maintained upon cessation of treatment. Patients in thecontrol group maintain the same mean arterial pressure throughout boththe control period and the experimental period. Findings of reduction innormotensive individuals means that paradoxical pulsed therapy findsprophylactic use in preventing the onset of hypertension in individualsidentified as predisposed to the condition

Although the foregoing invention has been described in some detail byway of illustration and example for purposes of clarity ofunderstanding, it is readily apparent to those of ordinary skill in theart in light of the teachings of this invention that certain changes andmodifications may be made thereto without departing from the spirit orscope of the appended claims.

Accordingly, the preceding merely illustrates the principles of theinvention. It will be appreciated that those skilled in the art will beable to devise various arrangements which, although not explicitlydescribed or shown herein, embody the principles of the invention andare included within its spirit and scope. Furthermore, all examples andconditional language recited herein are principally intended to aid thereader in understanding the principles of the invention and the conceptscontributed by the inventors to furthering the art, and are to beconstrued as being without limitation to such specifically recitedexamples and conditions. Moreover, all statements herein recitingprinciples, aspects, and embodiments of the invention as well asspecific examples thereof, are intended to encompass both structural andfunctional equivalents thereof. Additionally, it is intended that suchequivalents include both currently known equivalents and equivalentsdeveloped in the future, i.e., any elements developed that perform thesame function, regardless of structure. The scope of the presentinvention, therefore, is not intended to be limited to the exemplaryembodiments shown and described herein. Rather, the scope and spirit ofpresent invention is embodied by the appended claims.

What is claimed is:
 1. A method of treating a subject for a diseasecondition, said method comprising: enhancing at least one symptom ofsaid disease condition in a manner effective to cause said subject tomount a compensatory response effective to treat said disease condition.2. The method according to claim 1, wherein said enhancing comprisesapplying a stimulus to said subject.
 3. The method according to claim 2,wherein said stimulus is a pharmacological agent.
 4. The methodaccording to claim 2, wherein said stimulus is an electrical stimulus.5. The method according to claim 1, wherein said disease condition is amanifestation of an irregularity in a homeostatic pathway.
 6. The methodaccording to claim 5, wherein said disease condition is manifested bychronic sympathetic bias.
 7. The method according to claim 6, whereinsaid disease condition is a cardiovascular disease.
 8. The methodaccording to claim 7, wherein said cardiovascular disease ishypertension.
 9. The method according to claim 7, wherein said stimulusis a pharmacological agent.
 10. The method according to claim 9, whereinsaid pharmacological agent is an adrenergic agonist.
 11. The methodaccording to claim 1, wherein said disease condition is a neurologicalcondition.
 12. The method according to claim 11, wherein saidneurological condition is depression.
 13. The method according to claim12, wherein said agent is a serotonin antagonist.
 14. The methodaccording to claim 1, wherein said disease condition is an immunecondition.
 15. The method according to claim 14, wherein said immunecondition is asthma.
 16. The method according to claim 15, wherein saidagent is a proinflammatory agent.
 17. The method according to claim 1,wherein said disease condition is an endocrine system condition.
 18. Themethod according to claim 17, wherein said disease condition isdiabetes.
 19. The method according to claim 18, wherein said agent is aninsulin blocker.
 20. The method according to claim 1, wherein saidadministering is of limited temporal duration.
 21. The method accordingto claim 1, wherein said method comprises monitoring said subject. 22.The method according to claim 21, wherein said method comprises applyinga first stimulus to said subject and monitoring said subject for aresponse thereto; and applying a second stimulus to said subject,wherein said second stimulus is determined based on said monitoredresponse to said first stimulus.
 23. The method according to claim 22,wherein said first stimulus is a pharmacological agent.
 24. The methodaccording to claim 22, wherein said first stimulus is electrical energy.25. An algorithm recorded on a computer-readable medium foradministering a stimulus to said subject in accordance with method ofclaim
 2. 26. A system comprising: an algorithm recorded on acomputer-readable medium for administering a stimulus to a subjectaccording to a method of claim 2; and a stimulus producing component.27. The system according to claim 26, wherein said stimulus producingcomponent is a pharmacological agent delivery device.
 28. The systemaccording to claim 27, wherein said stimulus producing component is anelectrical energy applying device.
 29. A kit comprising: a stimulusproducing component; and instructions for a stimulus to a subjectaccording to the method of claim
 2. 30. The kit according to claim 29,wherein said stimulus producing component is a pharmacological agentdelivery device.
 31. The kit according to claim 29, wherein saidstimulus producing component is an electrical energy applying device.